Textbook of Forensic Medicine & Toxicology [2 ed.] 9788184487060, 8184487061

Table of contents :
Front Matter
Cover
Contributors
Foreword
Preface
Acknowledgements
Contents
PART I: INTRODUCTION AND EVOLUTION
1. Introduction
2. Historical Perspective
PART II: MEDICAL JURISPRUDENCE
3. Doctor and the Law
4. Ethics of Medical Practice
5. Euthanasia (Mercy Killing)
6. Consumer Protection Act and Medical Profession
7. Human Organ Transplantation Legal and Ethical Asp
8. Ethical and Legal Aspects of AIDS
9. Medical Records
10. Medical and Legal Aspects of Anaesthetic and Oper
PART III: FORENSIC PATHOLOGY
11. Forensic Identity
12. Forensic DNA Profiling
13. Thanatology
14. Postmortem Examination
15. Violent Asphyxial Death
PART IV: CLINICAL FORENSIC MEDICINE
16. Trauma, Injury and Wound
17. Regional Injuries
18. Transportation Injuries
19. Effects of Injury
20. Firearms and Explosive Injuries
21. Effects of Cold and Heat
22. Electrocution, Lightning and Radiation
23. Trauma in its Medicolegal View Points
24. Domestic Violence-Medical and Legal Aspects
25. Torture and Medical Profession
26. Sexual Jurisprudence
27. Infanticide, Foeticides and Child Abuse
28. Forensic Psychiatry
29. Forensic Radiology
30. Forensic Engineering
PART V: FORENSIC TOXICOLOGY
31. General Principles
32. Corrosive Poisons
33. Irritant Poisons
34. Neurotoxics
35. Cardiac Poisons
36. Asphyxiants
37. Domestic Poisons
38. Poisoning by Therapeutic Substances
39. Food Poisoning and Poisonous Foods
40. Drug Dependence and Drug Abuse
Appendices
Index

Citation preview

Textbook of Forensic Medicine and Toxicology

Textbook of Forensic Medicine and Toxicology SECOND EDITION

Nageshkumar G Rao BSc MBBS MD FIAMLE FICFMT

Professor of Forensic Medicine SDM College of Medical Sciences and Hospital Sattur, Dharwad 580 009, Karnataka, India President National Foundation of Clinical Forensic Medicine (NFCFM) Editor-in-Chief, IJFR Formerly State Medicolegal Consultant, Government of Karnataka Professor and Head Department of Forensic Medicine Kasturba Medical College, Mangalore Professor and Head, Director of PG Studies Department of Forensic Medicine Kasturba Medical College, Manipal Professor and Head Department of Forensic Medicine and Toxicology Sikkim Manipal Institute of Medical Sciences, Sikkim Professor and Head Department of Forensic Medicine Chairman, Department of Medical Education Meenakshi Medical College Research Institute and Hospital Kanchipuram, Tamil Nadu President, Karnataka Medico Legal Society Vice President, Indian Academy of Forensic Medicine Editor-in-Chief, Journal of Indian Academy of Forensic Medicine (JIAFM) Editor-in-Chief, Journal of Karnataka Medicolegal Society (JKAMLS)

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Overseas Offices • North America Office, USA, Ph: 001-636-6279734 e-mail: [email protected], [email protected] • Central America Office, Panama City, Panama, Ph: 001-507-317-0160 e-mail: [email protected], Website: www.jphmedical.com • Europe Office, UK, Ph: +44 (0) 2031708910 e-mail: [email protected] Textbook of Forensic Medicine and Toxicology © 2010, Nageshkumar G Rao All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher. This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2000 Reprint: 2006 Second Edition: 2010 ISBN 978-81-8448-706-0

Typeset at JPBMP typesetting unit Printed at

Dedicated to my beloved parents

Late Sri S Gopal Rao and Late Smt Sharada Bai G Rao

“If I have the belief that I can do it, I shall surely acquire the capacity to do it, even if I do not have it at the beginning”. —Mahatma Gandhi

CONTRIBUTORS LITERATURE BL Meel MD, DHSM (Natal), DOH (Wits), M Phil Professor and Head Department of Forensic Medicine Faculty of Health Sciences University of Transkei P/bag X1 UNITRA Umtata 5100, South Africa (Chapter 25: Torture and Medical Profession)

Nirmala N Rao MDS Associate Dean, Professor and Head Dept of Oral Pathology Manipal College of Dental Sciences Manipal Karnataka, India (Chapter 11: Forensic Identity—Age and Identity by Dentition)

B Santhosh Rai PV Assoc. Professor of Radiodiagnosis KMC, Mangalore, Karnataka (Chapter 29: Forensic Radiology)

Hadi Sibte MBChB, DMJ, PhD Senior Lecturer in Forensic Medicine and Genetics School of Forensic and Investigative Sciences University of Central Lancashire Preston UK, PRI, 2HE (Chapter 12: Forensic DNA Profiling) Gamini Goonetilleke MBBS (Cey.), FRCS (Eng) Consultant Surgeon Sri Jayawardenapura General Hospital 22, Sulaiman Avenue Colombo 5 Sri Lanka (Chapter 20: Firearms and Explosure Injuries—Injuries due to Antipersonnel Landmines)

Anil Aggrawal MD Professor of Forensic Medicine A Gupta MD Punith Setia MD Asst. Professors of Forensic Medicine MAMC, New Delhi (Chapter 30: Forensic Engineering) PC Sarmah MD, LLB Professor and Head Dept. of Forensic Medicine and Toxicology Sikkim Manipal Institute of Medical Sciences Tadong, Gangtok, Sikkim (Appendix 3: Laws of Relevance to Medical Profession in India)

PHOTOGRAPHS B Santha Kumar MSc (FSc), MD, DFM, DNB (Forensic Med.) Professor and Head Dept. of Forensic Medicine Govt. Stanley Medical College Chennai, Tamil Nadu Shashidhar C Mestri MD Professor and Head Dept. of Forensic Medicine (Former Professor and Head Dept. of Forensic Medicine JSS Medical College, Mysore, Karnataka) KIMS, Chengalpettu Chennai, Tamil Nadu PWD Ravichnander MD, DNB (Forensic Med) Professor and Head Dept of Forensic Medicine (Formerly Professor and Head Dept of Forensic Medicine Mysore Medical College, Mysore, Karnataka)

PES Institute of Medical Sciences Kuppam, Chittor District Andhra Pradesh K Bhaskar Reddy MD Professor and Head Dept of Forensic Medicine SVT Medical College Thirupathi, Andhra Pradesh Uday Pal Singh MD Assoc. Professor in Forensic Medicine Kakathiya Medical College Warrangal, Andhra Pradesh VV Wase MD (Path), MD (Forensic Med) Dean, Professor of Forensic Medicine (Former Head, Dept of Forensic Medicine Grant’s Medical College, Mumbai) Sri Ramanand Thirth Medical College Ambajogai District, Beed, Maharashtra

Textbook of Forensic Medicine and Toxicology

MR Chandran MD Principal Professor of Forensic Medicine (Former Head, Dept of Forensic Medicine Medical College, Calicut) Amala Institute of Medical Sciences, Trissur, Kerala M Shahanavaz MD Assoc. Professor Department of Forensic Medicine and Toxicology (Former Assistant Professor of Forensic Medicine KMC, Mangalore, Karnataka) Sebha Medical College, Libya NG Revi MD Professsor and Head Dept of Forensic Medicine (Former Professor and Head, Police Surgeon Govt Medical College, Trissur) Jubilee Mission Medical College, Trissur, Kerala Zachariah Thomas MD Assistant Professor of Forensic Medicine Medical College, Kottayam, Kerala EJ Rodriguez MD Assoc Professor of Forensic Medicine Goa Medical College, Bambolim, Goa Kiran J MD Professor and Head Dept of Forensic Medicine Sri Devraj Ursu Medical College Kolara, Tamaka, Karnataka

B Suresh Kumar Shetty MD Assoc Professor of Forensic Medicine Kasturba Medical College Mangalore, Karnataka Prateek Rastogi MD Assoc Professor of Forensic Medicine Kasturba Medical College Mangalore, Karnataka Tanuj Kanchan MD Assistant Professor of Forensic Medicine Kasturba Medical College Mangalore, Karnataka Chaitra MBBS Tutor in Forensic Medicine Kasturba Medical College Mangalore, Karnataka Raj Kumar Karki MBBS Sr. Resident in Forensic Medicine Kasturba Medical College Mangalore, Karnataka Arjun Suri, Safal Shetty, Sampuran Acharya, Kartik Valliappan, II MBBS Students in Forensic Medicine (2008-2009), Kasturba Medical College Mangalore, Karnataka

Shreemathi Rajagopal MD Retired Professor and Head Dept of Forensic Medicine St. John’s Medical College Bengaluru, Karnataka

Ms Nirmala, Dinseh, Yogish, Suresh, Monappa, Janardhan, Joseph Non Teaching Staff, Department of Forensic Medicine Kasturba Medical College Mangalore, Karnataka

Uday Kumar MD Professor and Head Dept of Forensic Medicine (Former Professor and Head Dept of Forensic Medicine, FMMC, Kankanady, Mangalore) Shri Laxmi Narayana Institute of Medical Sciences and Research, Pondicherry

Divin Kumar, Balakrishna, Narayana Kotian, Sharath Kumar, Jayaram, Ms Jayanthi, Ms Ranjini Shetty, Ms Rathi, Ms Sushma College Office Staff KMC, Mangalore, Karnataka

Arbind Kumar MD, DNB (Forensic Med) Professor of Forensic Medicine Patna Medical College, Patna, Bihar Binoy Kumar Bastia MD Professor of Forensic Medicine JNMC, Belgaum, Karnataka Mahabalesh Shetty MD Professor and Head Dept of Forensic Medicine KSHEMA, Derla Katte Mangalore, Karnataka viii

Ritesh G Menezes MD, DNB (Forensic Med) Assoc Professor of Forensic Medicine Kasturba Medical College Mangalore, Karnataka

Ms Shreemati Staff Nurse, MCODS Mangalore, Karnataka M Rajesh MD Assistant Professor, MMCRI Kandreepuram, Tamil Nadu Gokul, Sakthi Vignesh, Mohammad Halith, Dinesh Kumar, Aravind Arokiarajan, Veereshwara Raju, Praveen, Ms Gayathri, Ms Sindhuja Devi, Ms Lavanya II MBBS Students in Forensic Medicine (2006-2007) MMCRI, Kancheepuram Tamil Nadu

REVIEW PANEL A Busuttil MD, FRCPath, DMJ, FRCP (Eng), FRCP(Glas), FRCS (Edin)

Regius Professor of Forensic Medicine University of Edinburgh Edinburgh, UK S Subramaniam MBBS, DMJ Clin, DMJ Path, MRCP (Forensic Med)

Forensic Pathologist, Dept. of Pathology Kuwait University Kuwait L Thirunnavakarasu MD Retired Professor and Head Dept of Forensic Medicine Bangalore Medical College and St John’s Medical College Bengaluru, Karnataka, India Alexander F Khakha MD Professor and Head Dept. of Forensic Medicine Vardhaman Mahavir Medical College R. No. 204, Safdarjung Hospital New Delhi, India B Santha Kumar (Capt) MD Professsor and Head Dept. of Forensic Medicine Govt. Stanley Medical College Chennai Tamil Nadu, India Arun Kumar Agnihotri MD Additional Professor Dept of Forensic Medicine SSR Medical College Mauritius M Shahanavaz MD Assoc. Professor Department of Forensic Medicine and Toxicology (Former Assistant Professor of Forensic Medicine KMC, Mangalore, Karnataka) Sebha Medical College, Libya Dinesh Rao MD, DMJ Director (Actg), Legal Medicine Unit MNS, Kingston, Jamaica VV Wase MD (Path.), MD (Forensic Med),

Rajagopal (Maj Gen-Retd) AVSM, MS, Dean Professor of Oncosurgery (Former Dean, AFMC, Pune, Maharashtra) KMC, Mangalore Karnataka, India BH Tirpude Professor and Head Dept of Forensic Medicine Mahatma Gandhi Institute of Medical Sciences Sevagram, Wardha Maharashtra, India Narayana Reddy MD, LLB, LLM Principal, Professor and Head Dept of Forensic Medicine Osmania Medical College and Gen Hospital Hyderabad, Andhra Pradesh, India L Fimate MD Director, Professor of Forensic Medicine Regional Institute of Medical Sciences Imphal, Manipur, India PK Chattopadhyay PhD Director, Amity Institute of Advanced Forensic Science Research and Training Amity University Campus Noida, UP, India NG Revi MD Professsor and Head Dept of Forensic Medicine (Formerly Professsor and Head, Police Surgeon Govt. Medical College, Trissur) Jubilee Mission Medical College Trissur, Kerala, India Mukesh Yadav MD Professor and Head Dept of Forensic Medicine and Toxicology School of Medical Sciences and Research Greater Noida UP, India CB Jani MD Professor and Head Dept of Forensic Medicine PS Medical College Karamsad Dist, Anand Gujarat, India

DNB (Forensic Med), LLB, Dean

(Former Head, Dept of Forensic Medicine Grant Medical College, Mumbai) Sri Ramanand Thirth Medical College Ambajogai District, Beed Maharashtra, India

Silvano CA Dias Sapeco MD Professor and Head Dept. of Forensic Medicine Goa Medical College Bambolim, Goa, India

Textbook of Forensic Medicine and Toxicology

MS Usgaonkar MD Professor and Former Head Dept of Forensic Medicine Sri Krishna Institute of Medical Sciences Kharad, District Satara Maharashtra, India NK Aggrawal MD Professor and Head Dept of Forensic Medicine and Toxicology University College of Medical Sciences Shahadhara, New Delhi, India BM Nagraj MD Professor and Head Dept of Forensic Medicine Dr Ambedkar’s Medical College KG Hill, Bengaluru Karnataka, India Shashidhar C Mestri MD Professor and Head Dept of Forensic Medicine (Formerly Professor and Head Dept. of Forensic Medicine JSS Medical College Mysore) KIMS, Chengalpettu, Chennai Tamil Nadu, India KR Nagesh MD Professor and Head Dept of Forensic Medicine Father Muller’s Medical College Kankanady, Mangalore Karnataka, India Ananad Menon MD Assoc Professor Dept of Forensic Medicine Kasturba Medical College Mangalore, Karnataka, India Ritesh G Menezes MD, DNB (Forensic Med) Assoc Professor Dept of Forensic Medicine Kasturba Medical College Mangalore, Karnataka, India

x

Prabeer Kumar Dev MD Assoc Professor Department of Forensic Medicine and State Medicine North Bengal Medical College Susrutha Nagar Siliguri West Bengal, India Prateek Rastogi MD Assoc Professor of Forensic Medicine Kasturba Medical College Mangalore Karnataka, India Tanuj Kanchan MD Assistant Professor of Forensic Medicine Kasturba Medical College Mangalore Karnataka, India Nirmala N Rao MDS Associate Dean, Professor and Head Dept of Oral Pathology Manipal College of Dental Sciences Manipal, Karnataka Chetna Chandrashekhar Assistant Professor in Oral Pathology Manipal College of Dental Sciences Manipal, Karnataka, India Shweta Rehani Assistant Professor in Oral Pathology Manipal College of Dental Sciences Manipal, Karnataka, India MM Nadig BSc LLB, LLM, PhD Principal Vaikunt Baliga College of Law Udupi, Karnataka, India PV Bhandary MD Consultant Psychiatrist, Director Dr AV Baliga Memorial Hospital VM Nagar, Doddanagudde Udupi Karnataka, India

FOREWORD TO THE SECOND EDITION Ramdas M Pai President & Chancellor

Law and medicine are the world’s oldest noble professions that are claimed to have been wedded long ago, transforming into a science of facts assisting in to resolve the social evils. No other professional endeavour has ever struggled in recent decades as forensic medicine to develop into what it is today! Indeed, with escalating violence, terrorism and such worldwide criminal activities, it is obvious that degree of application of forensic principles and its concepts accomplished a lot in solving the crime mysteries fascinatingly. As a doctor, a forensic expert applies his/her medical knowledge to the knowledge of law not only in solving the crime, but also imparting justice in the court of law to the distressed or dead. Professor Nageshkumar G Rao, was our faculty, worked as Head of the Department of Forensic Medicine at Kasturba Medical College (KMC), Mangalore, has profound experience and knowledge to compile and revise this book. His research publications available in the world forensic literature have earned many honours conferred on to him by the various authorities in India. I understand that Dr Rao got the coveted honour of ICFMT Annual Congress Award, 2008. In 1987, Kasturba Medical College had conferred him with Dr TMA Pai Gold Medal for Research publication. I have gone through this revamped second edition of Textbook of Forensic Medicine and Toxicology. The book has very useful information for the medical and law students, and for the practising physicians and legal professionals. The publisher’s efforts to reprint the first edition clearly spell out the popularity of the book. Innumerable references cited in each chapter construe the scientific base for the book. The book also includes worthy appendices at the end, comprising of question bank providing theory and viva-voce questionnaires, varsity examination methodology and suggested syllabus in both theory and practical examinations. I am sure, the second edition of the book too will get very good reception. My best wishes to Prof Nageshkumar G Rao.

Ramdas M Pai

Declared as Deemed-to-be-University under Section 3 of the UGC Act, 1956

manipal.edu, Madhav Nagar, Manipal 576104, Karnataka, India  Ph: 91 820 2570064 Fax: 91 820 2570062  E-mail: [email protected]  www.manipal.edu

FOREWORD TO THE FIRST EDITION Forensic Medicine has claimed its full share in dramatic progress of medicine during the present century. No aspect of patient care is free from its growing impact and Medical Jurisprudence of yesteryears has moved from the fringes to the center stage of a doctor’s training. Today, forensic issues confront not only the specialist but also the young doctor treating a victim of violence in a village, a consultant facing a consumer claim and an investigator seeking informed consent for a new procedure. Forensic medicine has cast its mantle on every facet of the interaction between medicine and society. Unlike the predecessors, today’s physicians are called upon to deal with a new variety of problems, which impinge on science, ethics and law. In vitro fertilization, surrogate motherhood, brain death, organ donation, consumer protection and the living will raise unprecedented questions, which demand the attention of the best minds in medicine, jurisprudence and law. Furthermore, the spread of violence and increase in diabolical crimes has aggravated the problems for the practicing physician. To tackle the practical side of these questions, forensic medicine has summoned the resources of science in full measure— DNA technology for identity tests, neutron-activation analysis and scanning electron microscopy for crime detection and many other examples illustrate the scientific advances in its methodology. It is imperative that the medical student gains a clear understanding of the practical, legal and philosophical issues in forensic medicine during the course of his or her training. This is as important for his or her trouble-free practice as for the safety of the society whom he serves. Professor Nageshkumar G Rao has drawn upon his rich experience as a teacher in writing this book, which is primarily addressed to the medical students. They will find here a mine of up-to-date information on every aspect of forensic medicine, presented lucidly and expertly with collection of excellent color photographs and simple line drawings. The coverage includes ethics, legal procedures, consumer protection, thanatology, autopsy examination, trauma, toxicology, and other important topics. Professor Rao deserves our compliments for preparing this easily readable text which I hope will become popular among medical students and the practitioners of medicine. MS Valiathan ChM, FRCS, FRCS (c)

Former Vice-Chancellor Manipal Academy of Higher Education (Deemed University) Manipal

FOREWORD TO THE FIRST EDITION Textbook of Forensic Medicine and Toxicology is a lucid elucidation of the essence of medicolegal aspects of medical practice, which is essential knowledge, nay, compulsory knowledge, for all medical students, and practicing doctors irrespective of their specialty. Professor Nageshkumar G Rao, presently our Head of the Department of Forensic Medicine and Director of Postgraduate studies, has been my student whom I know intimately, right from his undergraduate student days. After paying due obeisance to his postgraduate training and teaching expertise in the specialty of Forensic Medicine, I must confess that he has matured into a good teacher and an excellent communicator at the same time. The book is concise, but covers all vital aspects of Forensic Medicine. I feel it will be an asset to every practicing doctor to be kept with him for ready reference. With the consumer problems coming into medicine in a big way, this assumes greater significance. I wish we had taught our students the Indian code of ethics, which, in my opinion, is far superior to the Hippocratic ethics that we all swear by. Consumerism is a bane to the practising doctors; but we must remember that it is the medical profession, which has taken medicine to the market place and converted it into a business, like any other profit making business, to attract consumerism. “Never make money in the sick room” was Hippocratic dictum. With corporate business getting into hospitals based on the five-star western culture (while large hospitals in the West are closing down), it was inevitable that some checks and balances had to be introduced into the practice of medicine. The format and the printing of the book have been of very high order. Photographs, line drawings, flow charts, and tables in the book are relevant and extremely useful. Colour photographs presented in 60 plates with nearly 300 pictures are excellent. The language is simple and easily understandable. The book should be in the clinic of every practising doctor. This would be a blessing as a ready reference in the courtroom also. I see a bright future for this book. I feel it may help the exam going student as well. I wish the book all success. BM Hegde

MD FRCP (Lond) FRCP (Edinb) FRCP (Glasg) FACC

Vice-Chancellor Manipal Academy of Higher Education (Deemed University) Manipal

FOREWORD TO THE FIRST EDITION Forensic Medicine is a vast subject, which needs to be explored by an overburdened student, in very little time available to him. There are umpteen number of text books available in the market, but many of them give archaic information, which is no more relevant in the current scenario. Forensic medicine is a rapidly changing subject, and there was a dire need to look at it from a fresh angle. By their very nature, the existing books, were not able to do justice with this situation. They were existent in the market for a long time, and the authors were sometimes reluctant to jettison old and archaic information, which had earlier found favor with the students. I first met Nageshkumar G Rao, the author of this eminently readable book, more than a decade ago, during an academic conference in Berhampur, and was immediately struck by his academic brilliance. I couldn’t help being drawn towards him, and gradually found myself drifting closer and closer to him. During the next few years, we all saw him edit the Journal of the Indian Academy of Forensic Medicine, which undoubtedly had its best period under his stewardship. Not only did he edit the journal, but from time to time, published brilliant academic papers in it too. Many times I found that the papers were brilliant enough to have found a place in some more widely circulated journals originating from some Western countries, and I often spoke my heart out to him. I was struck by the answer he gave me. He told me, “Anil, we have to enrich our own journals, not the foreign ones.” Such was the commitment of this author towards Forensic Medicine, and Indian Forensic Medicine in particular. For a long time we all wanted to have a book, which could look at Indian forensic medicine from a fresh angle, and judging by my experiences with him, I had no doubt that it was Nagesh who could do it. When I was in the Edinburgh Medical School, Scotland, during the late eighties and early nineties, working with the doyen of Forensic Medicine, Professor Anthony Busuttil, I maintained close contact with him, and advised him in this direction. During the mid-nineties, I found myself in Japan working with Professor Katsuji Nishi, and later in Armed Forces Institute of Pathology, Washington DC with Dr Charles Stahl, and during those periods too I would often write to him, stimulating him to do this long pending job. I suspect, it was that stimulation which finally spurred him on to write this book. From then onwards, whenever I would actually meet him during an academic conference, I would always ask him what he had done in that direction. Last year, during the Annual IAFM conference at AIIMS, New Delhi he showed me some work he had done in this direction, and I was happy he had started. But when I first had a look at the complete manuscript, I couldn’t believe myself. Undoubtedly, I had expected a sterling book from him, but this was a different stuff altogether. It was concise and to-the-point, and yet contained all the latest stuff that should have rightly been there. For instance there is a detailed and scholarly treatment of latest Acts like The Consumer Protection Act, The Human Organs Transplantation Act and even the latest ethical and legal position on diseases like AIDS. No existing book on forensic medicine deals with these subjects as comprehensively as this one. Toxicology has been dealt with from a fresh angle too. The book has a number of diagrams, which make the text easier to comprehend. I suspect, whenever a new textbook comes to the market, the author owes an explanation not only to students, but to all his academic brethren. The question often asked is, “What was the need of a new book, when a plethora of textbooks were already available?”. But fortunately Nageshkumar G Rao will not have to go through this often embarrassing exercise. This book is in many ways different from the existing textbooks, and undoubtedly would come as a succor to all the students of this country and abroad. Anil Aggrawal

Professor of Forensic Medicine Maulana Azad Medical College New Delhi

PREFACE TO THE SECOND EDITION The book is a complete revitalization of its predecessor published around a decade ago. The publisher’s effort to reprint the previous edition earlier explains the popularity of the book. However, as an author I felt the need to revise the text on account of rapid advances and developments in forensic research globally. This edition was made possible by the combined efforts of nearly sixty brilliant academicians who served as the honorary review panel members and contributors of this book. The contributors helped me in improving the contents by providing new information, chapters, photographs and such other materials, while the review panel did the critical evaluation, appended recent advances, checked the language and made essential changes in the text. Dr Antony Busuttil, Regius Professor of Forensic Medicine of the University of Edinburgh; Dr S Subramaniam, Forensic Pathologist, Dept of Pathology, Kuwait University, Kuwait; Dr L Thirunnavakarasu, Retired Professor and Head, Dept of Forensic Medicine, Victoria Hospital, Bangalore Medical College and St. John’s Medical College, Bengaluru, Karnataka, India Dr Alexander F Khakha, Professor and Head, Dept of Forensic Medicine, Vardhaman Medical College, Safdar Jung Hospital, New Delhi, India and Dr B Santha Kumar, Professor and Head, Dept of Forensic Medicine, Govt. Stanley Medical College, Chennai, Tamil Nadu, India are five elite gentlemen and the best of my friends, whose selfless helps and remarkable efforts were crucial in revising this book. Besides, one of my brilliant postgraduate students–Dr Ritesh G Menezes, currently the Assoc. Professor of Forensic Medicine, at Kasturba Medical College, Mangalore, Karnataka, India has provided enduring and outstanding assistance in every phase of this venture. The first edition with two parts and 26 chapters has now been transformed into five parts and 40 concise and quality chapters packed with recent scientific advances. This edition also includes Appendices with four important addenda on Question Bank, Syllabus and Varsity Examination Aid, Laws of Relevance to Medical Profession in India and, Starvation and Neglect and Law. I have avoided too many case stories, historical anecdotes and quotes in this book, which I felt were superfluous and digressed from an academic point of view. The primary focus of this over 600 pages edition has been to incorporate relevant subject matter covering the syllabus recommended by the Medical Council of India using simple, comprehensible language. Over 1500 references, 700 photographs, 500 drawings, charts and tables found in this book will make the intricate theory of the subject extremely easy to understand for every reader. Especially students will not only excel in examinations but also achieve a thorough, usable knowledge of the subject for future professional life. M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India has published this book with great care using international standard printing technologies. They have designed an attractive cover, and utilized the power of coloured printing to create clear and beautiful pages so that reading of this book can be made pleasurable and interesting. Suggestions, constructive criticisms and thoughts for improving this book are more than welcome. Kindly email them to [email protected] I am sure that the forensic panorama provided in this edition will draw the attention of every reader and generate more response than the previous edition from students, professionals, clinicians, general practitioners, police and law officials alike. Nageshkumar G Rao

PREFACE TO THE FIRST EDITION Forensic Medicine and its methods have been in practice down the ages in history, but its scientific status and the development as a single discipline are of only recent origin. It appropriately now constitutes an integral part of undergraduate and postgraduate medical curricula. Modern Forensic Medicine, with an objective of making the subject specialty more wider, practical and to evolve into a tertiary specialty, has been re-introduced under five major subdivisions or newer taxonomy, viz, History and Developments in Forensic Medicine, Medical Jurisprudence, Forensic Pathology, Clinical Forensic Medicine and Forensic Toxicology as appreciated globally. In this book an attempt is made to introduce these newer concepts in India, as approved and proposed by the Medical Council of India (Gazette of India, May, 17, 1997). The 26 chapters presented in this edition, amalgamating all these five major subdivisions of the subject specialty, not only harvest of my personal experiences gained from the living and dead cases, I have been involved as medicolegal expert, but also blend with the cream of knowledge gathered from innumerable references in forensic literature. As a teacher in Forensic Medicine over the last two decades I have been feeling the need for a well-illustrated textbook, with precise and specific information. With short and lucid text and nearly 300 colored photographs, 200 B/W photographs, line drawings and simple flow charts, and 100 tables rendering easy understanding, recollection and reproduction in the examinations by medical students, I feel this textbook is the first of its kind in India. Perhaps this book could also cater to the needs of every medical practitioner, investigating police officer, lawyer, law enforcing authority, court and forensic scientist. My earnest hope is that this new book will find favorable response from all medical students and other concerned group of readers and find a suitable place in Forensic literature. Nageshkumar G Rao

ACKNOWLEDGEMENTS Life is always full of opportunities. During three and half decades of my career, working as professor and head of the department of forensic medicine, at four finest medical colleges in India, Kasturba Medical College, Manipal and Mangalore; Sikkim Manipal Institute of Medical Sciences, Sikkim; Meenakshi Medical College and Research Institute, Kancheepuram, Tamil Nadu; with an added privilege of availing membership of several scientific organizations globally; assigning examinership in forensic medicine, at several Universities of the country; status of Honorary State Medico Legal Consultant to Govt. of Karnataka and as an expert witness in various Courts of Coastal Karnataka — all have given me the unique opportunities of not only in understanding what really Indian forensic is, but also get acquainted with several academicians, medicolegal experts, legal luminaries which has allowed me to constitute the Hon. Review Panel and Contributors (literature and Photographs) for the second edition of my book. I am highly indebted to each one of them, who spared their precious time and helped me in improving this edition to its core, making it a finest epic. Enumerated below is their contribution with special acknowledgement: Some of these panel members have contributed selflessly their knowledge, special talents of photography, and time, in the form of case photographs to support the revamping process. Those who contributed and allowed use of their illustrations have been credited in the legends for the particular figures, and grateful acknowledgement is once again made here. As an author I explicitly wish to thank the following individuals in this regard: Drs Capt B Santha Kumar, Gamini Goonetilleke, Shashidhar C Mestri, PWD Ravichnander, K Bhaskar Reddy, Uday Pal Singh, VV Wase, NG Revi, MR Chandran, Zachariah Thomas, EJ Rodriguez, Kiran J, Shreemathi Rajagopal, Uday Kumar, Binoy Kumar Bastia, Mahabalesh Shetty, M Shahanavaz, Ritesh G Menezes, B Suresh Kumar Shetty, Prateek Rastogi, and Tanuj Kanchan. My special thanks goes to all those who have put their sincere efforts, time and help by volunteering as models/physical help in producing several photographs portraying the difficult themes discussed under Part-II: Medical Jurisprudence, replacing all the thematic cartoons of the previous edition. These include: Drs. M. Rajesh, Chaitra, Raj Kumar Karki; Forensic Medicine UG Students: Gokul, Praveen, Sakthi Vignesh, Mohammed Halith, Dinesh Kumar, Aravind Arokiarajan, Veereshwara Raju, and Ms. Lavanya, Gayathri, Sindhuja Devi, Arjun Suri, Safal Shetty, Sampurann Acharya, Karthik Valliappan; and Non teaching staff members: Dinseh, Yogish, Suresh, Monappa, Janardhan, Joseph, Divin Kumar, Balakrishna, Narayan Kotian, Sharath Kumar, Jayaram, Ms Nirmala, Jayanthi, Ranjini Shetty, Rathi, Sushma, and Shreemati. Individual chapters and/portion in the chapter wherever felt necessary was assigned to persons with a particular interest and confidence in the areas asked to read, review critically and do the corrections directly or to give suggestions to the author to implement, and to them are extended my sincere thanks. These include: VV Wase (Second Autopsy), BH Thirpude (Artefacts), NG Revi (Legal Procedure, Fast Track Court), L Fimate with MS Usgaonkar, Ritesh G Menezes and Tanuj Kanchan (Sexual Jurisprudence), NK Agarwal (Torture in Medical Practice), AF Khakha (Forensic Toxicology: General Principles, Corrosives and Irritants), CB Jani (Infanticide), Shashidhar C Mestri (Neurotoxics, Cardiac Poisons and Asphyxiants), Mukesh Yadav (Ethics of Medical Practice), PK Dev (Domestic Violence), Narayana Reddy (Medical Records, ML Aspects of Anaesthetic and Operative Deaths), PK Chattopadhyay (Forensic DNA Profiling), Arun Kumar Agnihotri (Drugs Dependence and Drug Abuse), Ananad Menon (Violent Asphyxial Deaths), KR Nagesh (Types of Autopsy Procedures, Trauma in its ML View Points), Prateek Rastogi (Thanatology), and PV Bhandary (Forensic Psychiatry), and Dinesh Rao (Blast Injuries). My deep appreciation to some of the senior reputed professionals with whom, I had lengthy academic acquaintance with close communications and rapport by e-mail/surface mail/telephonic talking, helped me by discussions, exchange of views of the technical and philosophical aspects of four major Parts of the book i.e. Part I: Introduction and Evolution, Part II: Medical Jurisprudence, Part III: Forensic Pathology, Part IV: Clinical Forensic Medicine and Part V: Forensic Toxicology, which resulted in thorough revision by inclusion of many of their conclusion and viewpoints. This list include Drs. Antony Busuttil, S Subramanyam, L Thirunnavakkarasu, and BM Nagraj, whose immeasurable help and calm wisdom can never be appropriately or adequately acknowledged; Drs Hadi Sibte (Forensic DNA Profiling), Gamini Goonetilleke (Injuries due to Antipersonnel Landmines), BL Meel (Torture and Medical Profession), Nirmala N Rao (Age and Identity by Dentition), PC Sarmah (Laws of Relevance to Medical Profession in India), B Santhosh Rai PV (Forensic Radiology), Anil Aggrawal, with A Gupta and P Setia (Forensic Engineering), for readily accepting and contributing new chapters to my book in spite of busy schedules in their respective work places. All the drawings in the second edition were made by the artists at Jaypee Brothers Medical Publishers (P) Ltd. at New Delhi, as per hand drawn sketches submitted with the script. I gratefully acknowledge the assistance by this professional team of artists, which is an important part in any book.

Textbook of Forensic Medicine and Toxicology xxiv

I wish to express my solemn sentiments and sincere thanks to each of the authors/co-authors of the various books/ journals/articles/Websites whose references are being cited in the text of the book, without which the scientific base for the facts mentioned wouldn’t have been there. A special debt of gratitude is owed to Dr Ritesh G Menezes and Mr Divin Kumar faculty in Forensic Medicine Department and College Office respectively at KMC, Mangalore, Drs. Nirmala N Rao, Chetna Chandrashekhar, and Shweta Rehani, faculty in Oral Pathology Department, Manipal College of Dental Sciences, Manipal; for their painstakingly read and re-read not only the rough and final copies of the manuscript, but also all the press page proofs, thrice correcting errors in punctuation, spelling, grammar and syntax with a magnanimous devotion, prior to its approval for final press printing. My thanks are due to Dr Ramdas M Pai, Chancellor and President; and Dr HS Ballal Pro Chancellor of Manipal University, Manipal; Mr LC Amarnath, Former Vice Chancellor and Mr SD Dhakal, Former Registrar of Sikkim Manipal University, Sikkim; and Thiru Radha Krishnan, Chancellor, Thiru Sathanam, Registrar, Dr E Munirathnam Naidu, Former Vice Chancellor, and Dr Gunasagaran, Vice chancellor, Meenakshi University, Chennai, Tamil Nadu for their constant encouragement and support in accomplishing the book work. I am highly indebted to Mr Jitendar P Vij, CEO of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India and his team members Mr Tarun Duneja, Ms Chetna Malhotra, Ms Samina Khan, Mr KK Raman, Mr DC Gupta and Mr Bharat Bhushan, all are known to me over last 7-8 years for their kind co-operation, hard work and all skills of maintaining brilliance in printing. I appreciate the commendable patience they have and encouraging words they always speak, which act as a source of inspiration to me, often suggesting me to contribute more to the book, making it a real ‘jewel in the crown’. The responsibility of completing this new edition would have been impossible without the sacrifice made by Nirmala my wife and Ganesh my son, daughter Nikhila and her husband Ajith; allowing to me to spare the family time in reading/writing for the book. To each one I propose my heart-felt appreciations and sentiments.

CONTENTS PART I: INTRODUCTION AND EVOLUTION 1. Introduction ------------------------------------------------------------------------------------------------------------------------------------- 1 2. Historical Perspective ----------------------------------------------------------------------------------------------------------------------- 3

PART II: MEDICAL JURISPRUDENCE 3. Doctor and the Law ------------------------------------------------------------------------------------------------------------------------- 7 4. Ethics of Medical Practice -------------------------------------------------------------------------------------------------------------- 23 5. Euthanasia (Mercy Killing) -------------------------------------------------------------------------------------------------------------- 45 6. Consumer Protection Act and Medical Profession --------------------------------------------------------------------------- 48 7. Human Organ Transplantation: Legal and Ethical Aspects --------------------------------------------------------------- 52 8. Ethical and Legal Aspects of AIDS ------------------------------------------------------------------------------------------------- 55 9. Medical Records ----------------------------------------------------------------------------------------------------------------------------- 57 10. Medical and Legal Aspects of Anaesthetic and Operative Deaths ---------------------------------------------------- 59

PART III: FORENSIC PATHOLOGY 11. Forensic Identity ----------------------------------------------------------------------------------------------------------------------------- 65 12. Forensic DNA Profiling ----------------------------------------------------------------------------------------------------------------- 119 13. Thanatology ---------------------------------------------------------------------------------------------------------------------------------- 133 14. Postmortem Examination -------------------------------------------------------------------------------------------------------------- 162 15. Violent Asphyxial Death --------------------------------------------------------------------------------------------------------------- 194

PART IV: CLINICAL FORENSIC MEDICINE 16. Trauma, Injury and Wound ------------------------------------------------------------------------------------------------------------ 221 17. Regional Injuries -------------------------------------------------------------------------------------------------------------------------- 234 18. Transportation Injuries ------------------------------------------------------------------------------------------------------------------ 259 19. Effects of Injury --------------------------------------------------------------------------------------------------------------------------- 266 20. Firearms and Explosive Injuries ---------------------------------------------------------------------------------------------------- 272 21. Effects of Cold and Heat -------------------------------------------------------------------------------------------------------------- 307 22. Electrocution, Lightning and Radiation ----------------------------------------------------------------------------------------- 320 23. Trauma in its Medicolegal View Points ------------------------------------------------------------------------------------------ 329 24. Domestic Violence—Medical and Legal Aspects ---------------------------------------------------------------------------- 338 25. Torture and Medical Profession ----------------------------------------------------------------------------------------------------- 345 26. Sexual Jurisprudence -------------------------------------------------------------------------------------------------------------------- 351 27. Infanticide, Foeticides and Child Abuse ---------------------------------------------------------------------------------------- 382 28. Forensic Psychiatry ----------------------------------------------------------------------------------------------------------------------- 395 29. Forensic Radiology ----------------------------------------------------------------------------------------------------------------------- 408 30. Forensic Engineering --------------------------------------------------------------------------------------------------------------------- 414

Textbook of Forensic Medicine and Toxicology

PART V: FORENSIC TOXICOLOGY 31. General Principles ------------------------------------------------------------------------------------------------------------------------ 419 32. Corrosive Poisons ------------------------------------------------------------------------------------------------------------------------- 450 33. Irritant Poisons ----------------------------------------------------------------------------------------------------------------------------- 458 34. Neurotoxics ---------------------------------------------------------------------------------------------------------------------------------- 494 35. Cardiac Poisons ---------------------------------------------------------------------------------------------------------------------------- 539 36. Asphyxiants ---------------------------------------------------------------------------------------------------------------------------------- 545 37. Domestic Poisons ------------------------------------------------------------------------------------------------------------------------- 555 38. Poisoning by Therapeutic Substances -------------------------------------------------------------------------------------------- 559 39. Food Poisoning and Poisonous Foods -------------------------------------------------------------------------------------------- 561 40. Drug Dependence and Drug Abuse ----------------------------------------------------------------------------------------------- 563 Appendices -------------------------------------------------------------------------------------------------------------------------------------- 567 Index --------------------------------------------------------------------------------------------------------------------------------------------- 601

xxvi

1 Medicine and Law were wedded from the earliest times, perhaps from the perceived necessity of protecting the community from the irresponsible acts of unqualified medical practitioners and quacks. Religion and superstition were intimately entangled with the medical art for time immemorial and this has also rubbed on to the dealings between those practicing medicine and those practicing law. From this interaction between these two professions of medicine and of law, emerged the specialist discipline and later the academic subject, forensic medicine. DEFINITION Forensic medicine is defined as that branch of medicine, which deals with the application of medical and paramedical scientific knowledge to the knowledge of both civil and criminal law in order to aid administration of justice.1-10 The word forensic is derived from the Latin word forensis, which implies something pertaining to the forum. In ancient Rome, the ‘forum’ was the communal meeting or market place where those with public responsibility discussed civic and legal matters, and where justice was dispensed and indeed seen by the public to be dispensed.2,4,7-10 In ancient India also, settlement of disputes was done by Panchayat where a group of panchas or five village elders were authorized to settle the dispute.6,8 Thus, the word forensic essentially conveys any issue related to the debate in relation to medical matters that can occur in a court of law. FORMER TERMINOLOGIES Forensic medicine was earlier known as Medical Jurisprudence (Juris meaning Law and prudentia meaning knowledge). Indeed the first university chairs in this subject also bear the additional title of Medical Police.3 The specialist in this discipline was supposed to be knowledgeable in matters of public health and hygiene, industrial health, epidemics of disease and other matters, which nowadays pertain together to the specialty of Public Health Medicine. For this reason also Social Medicine (Medicina Socialis) was thought to fall within the remit of the same specialist and this is still the case in the continent of Europe, e.g. France, Portugal and Italy.1-3 Social medicine pertains to medical matters related to employment and includes such other, matters as disease and injuries acquired at work, compensation for such, through insurance companies, and so on. In the Anglo-Saxon scheme of things and in those other systems derived from it, the specialist

Introduction

in forensic medicine does not have this additional clinical and community-related remit. This discipline has also been termed as State Medicine, which was the code of medical ethics and practice developed to regulate the code of conduct for registered medical practitioners, to guide and regulate the professional activities of the doctors and to standardize and supervise the medical profession. In the continent of Europe, the term Legal Medicine is often preferred and accepted to explain the interaction of professions of medicine and law.3-5 This range in terminology should direct the reader to the nuances of practice that exist worldwide in this specialty. It is, perhaps more important that the specialty is not taken to include forensic science as an integral and essential part of it. Although in a number of countries scientists and medical practitioners rub shoulders with each other and often work in the same department, there should not be a conscious or subconscious trend to mix the two specialists: Doctors may be scientists, but are not necessarily so. Doctors offer opinions based on their observations. In the same vein scientists are rarely medical men, but they measure accurately the characteristics of physics, chemistry, biology, etc. in which they are involved. To ensure that the best advice is given to lawyers, it is essential that our legal colleagues and the courts are made well aware of such a distinction and the reasons and situations in which it should be made. The two main aspects of legal medicine are pathology and clinical work. Forensic Pathology is practised by those who are able to carry out autopsies and who have the appropriate level of knowledge and expertise to distinguish the various pathological processes which may occur in the human body as a consequence of aging, natural processes, disease and injuries of various types.7-10 The Clinical Forensic Medicine deals with those who are still alive and on whom a medicolegal opinion is required. This includes those who have been traumatised physically and/or sexually, but who have not succumbed to their injuries, those who are under the influence of alcohol and/or drugs in relation to such matters as driving, human rights abuses, etc.7-10 The latter medical practitioners have been referred to as police surgeons, casualty surgeons, forensic medical examiners, and this branch of legal medicine is often specifically referrd to as forensic medicine.1-10 Thus, although medical practitioners have given evidence in the courts and professional opinions of their findings over

Chapter 1: Introduction

Part I: Introduction and Evolution

1

Part I: Introduction and Evolution 2

the years since the dawn of history, the academic and specialised status of this specialty and its development as a single specialised discipline with its own teaching programmes, diplomas and certificates, and curriculum of postgraduate specialisation is of only recent origin. In most countries this subject appropriately now constitutes an integral part of undergraduate and postgraduate medical curricula, and it is furthermore fully integrated into the training of police officers, lawyers, the judiciary and others. REFERENCES 1. Britain RP. Origins of Legal Medicine. Leges Barbarorum. Medicolegal Journal, 2003. 2. Cameron JW. The medicolegal expert. Med Sci Law 1980;20(1):313.

3. Camps, Francis E (Eds). Gradwohl’s Legal Medicine (3rd edn). Chicago: Year Book Medical Publishing Company, 1994. 4. Curran WJ. History and Development. In Modern Legal Medicine, Psychiatry and Forensic Medicine, WJ Curran, AL McCarry, LS Patty (Eds). FA Davis: Philadelphia, 1982. 5. Edinburgh A. and C. Black Encyclopaedia Britannica, 1886, Vol XXI (9th edn). Article: Salic Law, 214. 6. Mathiharan K, Patnaik AK. Modi’s Medical Jurisprudenc and Toxicology. 23rd edn. Lexis Nexis Butterworths 2005. 7. Mukharji JB. Forensic Medicine and Toxicology, Vol I, 2nd edn, Arnold Association, Kolkata, 2000. 8. Rao NG. Forensic Medicine: Historical Perspectives (3rd edn), HR Publication Aid: Manipal, 2002. 9. Rao NG. Forensic Pathology, 6th edn, HR Publication Aid, Manipal, 2002. 10. Parikh CK. Parikh’s Textbook of Medical Jurisprudence and Toxicology (6th edn) CBS, Mumbai, 2000.

ORIGIN OF THE TERMINOLOGY FORENSIC MEDICINE The study of primitive cultures reveals a close relationship between magic (witchcraft) of the sorcerer, shaman, witch doctor, etc. and development of science and medicine. With the evolution of civilisation and its general progress, Legal medicine was born as a separate branch of medical discipline on its own merit, and has now reached its present professional and academically respected status.1-5 The history of a subject is always considered as the key to the past, explanation of the present and/or signpost for the future. An effort has been made to provide brief details of the early developments in this specialty through the different centuries as an aide memoir to those researching its historical background. 4000-3000 BC Existing records confirm an interaction between legal and medical matters and this is to be found in the histories of the Sumerian, Babylonian, Indian, Egyptian, Assyrian civilisations apart from Chinese and Indian data on Materia Medica which include in them information on many poisons. It has been accepted widely that the Indus Valley Civilisation (3250-200 BC) is much more ancient than written chronicles on Indian history. Forensic medicine as it is practised today in India has attained its present state of development and high probity by passing through several phases of evolution. Amidst the anciently entrenched bonds of the medical arts with superstition, religion, magic, mysticism, folklore and custom, etc. through various centuries and generations, the modern growth and evolution of Indian civilisation had developed an Indian system of medicine, based on the accepted Western system of medicine mainly due to many years of British domination.4-14 3000-1000 BC Imhotep (2980 - 2900 BC), the Grand Vizier is considered as the first medicolegal expert. He was both Chief Justice and the Chief/Personal Physician to Pharaoh Zoster, the ruler of Egypt. He was claimed to be the God of Medicine. Furthermore, in ancient Egypt, the actual practice of medicine was subject to legal provisions. The doctor was punished for the wrong treatment of patient. Stab injuries were recognised for their lethal potential. Egyptian doctors were aware (like Indian doctors of the same period) that fractures of skull could occur without any overlying soft tissue injury. The Egyptians were very proficient in the art of preserving the dead body by mummification. Criminal abortion was punishable during this period.1,9-11 From

Chapter 2: Historical Perspectives

2

Historical Perspectives

the clay cuneiform tablets and the Papyri as recovered from Samaria, Babylon, etc. a general idea about the then-current system of law, crime and punishment can be gleaned. Punishment, including corporal punishment and mutilation: Cutting of ears, hands, nose and feet, hard labor in prison for varying periods, the throwing of convicts to the crocodile or lion, etc. were well established as modes of punishment for the guilty.1,9 Evidence of medicolegal knowledge which was embodied can be found in early legal systems1,9 such as in the: • Code of Hammurabi of Babylon (2000-1000 BC), which is the oldest written code of law written by Hammurabi, King of Babylon at about 2200 BC. It is well known for its provision of punishment of physicians found wanting and guilty of improper treatment with the potential for civil and criminal responsibility. • Code of the Hittites (1400 BC), which constituted a lengthy table of legal compensation for personal injuries. 1000-50 BC The developments during this period are highlighted below.1,5,9,10 • In Greece, around 460-355 BC, Hippocrates, the physician of antiquity and the father of medicine, dealt in his teachings with medical ethics, lethality of wounds, causes of sudden death, etc. • Aristotle (384-322 BC) is regarded as Father of Modern Family Planning, as he advocated population control by inducing abortion before animation of fetus. He postulated upper age limit of procreation in males to be around 70 years, and age of menopause in females around 50 years. • The most important of the Pre-Christian legal codes was Roman Law, on which, to this very day, many principles of law throughout the world are based, and whose rationale and phraseology still pervades many legal systems, e.g. novus actus interveniens, res Ipsa Loquitor. The Lex Aquillia dealt with the lethality of wounds (572 BC). The Tabulae Duodecem contained a code of laws enacted in 451-450 BC. These tables contained a number of provisions of medico legal significance concerning matters such as competency of the mentally ill, gestation period for development of the human fetus, euthanasia, eugenics, etc. • The amicus curiae of Roman law: Literally translated this phrase meaning friend of the court who was appointed as advisor to the judge on matters requiring specialised knowledge. They are honorary advisors and paid no fees for their expert opinions or advices given. Thus, the effective utilisation of expert evidence in the judicial system had its origin in the Roman practice.

3

Part I: Introduction and Evolution

• In Rome, the operation of Caesarean section surgery was advised to save life of the child and also solution of medical problem of inheritance. • Antistius, the physician, opined by externally examining the body of Julius Caesar (100-44 BC) that out of 23 injuries on the body, the one that entered the chest between first and second rib was the mortal one. During the Time of Christ In the time of Christ in the Middle East there was both the local Jewish influence and as elsewhere the Roman influence. Suicide in Jewish law was regarded as abhorrent as there was the belief that the individual who took his own life was possessed by evil spirits and that by taking his life he would pass the evil spirits on to other members of the community.9 In Greece suicide was considered an act of self-destruction and rebellion against the Gods. In these cases the medical expert had to reach a decision as to whether the deceased person committed suicide and should therefore be punished. Punishment would usually consist of denial of the right to a funeral.9-11 In Rome, those soldiers who committed suicide were considered deserters and those criminals who committed suicide to escape punishment were also condemned.5,9,13 The priests in the temple decided on disease management and those who were cured particularly of leprosy had to be seen by the priests before they were declared as clean again and were able to join the community again.9,13 1st and 5th Century AD Literature of forensic interest was observed as early as 2nd-3rd century AD.5,14-16 Pliny the Elder in his treatise mentioned about suspended animation, sudden and natural deaths, suicide, etc. The Justinian Code (529-564 AD) prescribed regulation of medical practice and imposition of penalties for malpractice. It also recognised expert testimony. It has been clearly enunciated in the Digest that Physicians are not ordinary witnesses but they give judgement rather than testimony. The help of medical experts was sought especially in respect of proof of pregnancy and its duration, time of delivery, sterility, impotence, inheritance, rape, abortion, marriage, divorce, survivorship, mental illness, poisoning, etc. The Barbarians, who overthrew the Roman Empire, laid down in a statute that in the court of law, the help of medical experts should be taken to evaluate injuries, before meting out punishment. 5th-10th Century AD During this period there was a close relationship between the development of medicine and medical ethics and the teaching of the Catholic Church, which held both a political and religiously powerful position, which pervaded every aspect of life. Legal medicine extends all through the history in one form or another. In the fifth century, Germanic and Slavic people overthrew the Roman Empire in Western Europe. These tribes, Salian Franks, the Alemanni, the Goths, the Vandals and the Lombards were considered Barbarians and destroyers of culture and civilisation, and yet these people were the first to lie down by statute that medical experts should be used to determine the cause of death. They had moved beyond the practice of personal vendettas and called for individual and community responsibility.2 The Wergeld, or blood-price, was paid to the victim by the suspect criminal, or in the case of murder, to the

4

victim’s family and relatives. A necessary result of this system was an evaluation of the wounds by the courts, and the courts had to rely on the expertise of a competent medical person.2,4 There is clear reference to the use of these medical experts in the writings of the courts. The Lex Alemannorum gives precise anatomical details of wounds and the reparation given with the situation and gravity of these wounds and orders that medicolegal examinations were to be made for that purpose.2 Charlemagne (782-814 AD) in his Capitularies enjoined that the judges should seek medicolegal opinion from competent experts in cases of wounding, suicide, infanticide, rape, divorce, impotence, bestiality, etc.5 11th-12th Century AD Frederick II ordained that, would-be-physicians fulfill the following requirements if they wanted to practice the art of medicine as physicians; the candidate had to be: • Aged 21 years • Born legitimately • Studied logic (philosophy) for 3 years • Studied medicine for 5 years according to teaching of Hippocrates, Galen and Avicenna • Served a year’s apprenticeship • Had to pass an examination conducted by his teachers • He would have to take oath to treat the poor free and visit his patients as required. Hence, the medical teaching, training and practice in those days were restricted under law- thus, State Medicine was born.1-3,5 12th-15th Century AD In China, a handbook called Hsi Yuan Lu was published in 1250, which contained descriptions of postmortem examinations of bodies and pointed to differences between those injuries caused by sharp and blunt instruments. It also commented whether an individual found in water had died of drowning or had been dead beforehand, or if a burned individual had been dead before an onset of a fire.4,10 Other achievements during this period can be summarised as below: • A public inquest was made obligatory in cases of sudden death in England with crowners (now coroners) being appointed for this purpose by the monarchy and entrusted with keeping the King’s please. • In 1209, Pope the Innocent III, ordained the appointment of doctors in Law Courts for examination and opinion in case of injuries. • In 1249, Hugo De Lucca, a famous surgeon, was appointed as medicolegal expert in Bologna, Italy. • In 1374, the Pope, through a Bill, allowed autopsy examination with the penalty of excommunication being withdrawn from those involved in such examinations. 16th-17th Century AD Records of forensic pathology in Europe began in 1507 when a volume known as the Bamberg Code appeared. Twenty-three years later Emperor Charles V issued a more extensive penal code called the Constitutio Criminalis Carolina. These two documents underlined the importance of forensic pathology by requiring that medical testimony be made available to the courts, and especially in trials that questioned the manner of death as infanticide, homicide, abortion, or poisoning.4,10 Records show that wounds were opened to show the depth and direction,

17th-18th Century Following achievements during the period are considered worth remembering:5 • Paulo Zacchia, a papal physician, published Quaestiones medicolegales covering not only different aspects of Forensic Medicine but also that of public health and pastoral medicine in 17th century. • Valentini: in 1701 published Pandectae medico-legalese— a work to challenge that of Zacchia. • The first medicolegal journal was published in Berlin under the Editorship of Uden and Pyl in the latter part of 17th century. • Antoine Louis, Chaussier, Mahon, Fodere, Orfila (Father of modern toxicology) from France, and Henke, Mende and Johan Ludwig Casper from Germany were considered as the famous medicolegal experts. The latter’s monumental work (1856), entitled Praktisches Handbuch der Gerichtlicvhen Medizin was published through 9 editions with an English translation in 1861-65. • Chairs of Professorship in Medical Jurisprudence was established in German, Italian and French Universities in the early part of 18th century. • Andrew Duncan became the first Professor in the subject at Edinburgh and gave his first set of lecturers in 1807. Sir Robert Christison became Professor of Medical Jurisprudence at the age of 24 years in 1882. He initially became famous as a medicolegal expert at this time in Case of Burke and Hare and later produced the first complete British pharmacopoeia. • This century was marked for substantial developments in medicolegal relations and by severe struggles to encourage the more effective use of scientific methods. In courts of the past, the proof of innocence in the criminals was essentially based on superstitions and physical evidences. The criminal defending himself was expected to display his innocence under various methods applied, such as: – Trial by ordeal: It was common in all countries and some of the examples in practice were:

– – – –

The test of fire: The defendant was required to carry hot coal or iron bar and if his body got burnt, he was declared guilty. The ordeal by water: Here the accused held submerged in water for sometime, was disproved to be guilty if did not turn unconscious. The poison test: The deadly poisons were forced upon the accused and slightest discomfort shown by him declared his guilt. Death by compurgator: Parties in both criminal and civil cases could satisfy the demands of the court by swearing to the facts under Christian oath.

Chapter 2: Historical Perspectives

although complete autopsies may not have been performed in every case.5,10,11 As the centuries progressed, forensic pathology became more and more utilised by the investigators to help solve crimes, to distinguish between homicidal and accidental drowning, descriptions of bullet and stab wounds, findings in asphyxia cases, infanticide and natural death.1,9 Michaelis and Bohn held the first formal lectures in forensic pathology at the University of Leipzig, Germany, where students were instructed in natural and violent deaths. The achievement of the century is that the Bishop of Bamberg codified medical evidence in all cases of violent deaths in penal code officially.5,9 • Ambroise Pare wrote a treatise on different medicolegal problems including death from various causes, how to differentiate antemortem injuries from postmortem ones, etc. Model Case reports were also incorporated.9 • Methodus Testificandi dealing with wounds, poisoning and sexual matters were compiled by Codronchius, an Italian physician of Imola.5 • Fortunatus Fidelis of Palermo, Sicily, published a systematic treatise on legal medicine in 4 volumes entitled De Relationibus Medicorum.5

In 19th Century AD One of the greatest boon implemented to the mentally unsound in English law during this century was McNaughten Rule. Alfred Swaine Taylor is the most famous name in English Legal Medicine in 19th Century. He became a Professor of Medical Jurisprudence at the Guy’s Hospital Medical School in 1834. This century happens to have been associated with several contributions to the subject and most popular among them are: Alfred Swaine Taylor’s first edition of Principle and Practice of Medical Jurisprudence published in the year 1865. The book has been revised through several editions by reputed medicolegalists of the period and still accepted as a classic book on the subject. FORENSIC MEDICINE IN INDIA Indian Forensic medicine and its evolution can be perceived through 3250-200 BC in the Indus Valley Civilization, and other treatises on Indian history such as Manusmriti (3102 BC), Vedic Literatures of Vedic age (2000-1000 BC), Agnivesa Charaka Samhita (700 BC). Sushruta Samhita (200-300 AD) and Kautilya’s (Chanakya’s) Arthashastra (300-500 AD), though adds to this, the most recent well recorded evolutions occurred during 1000-1600 AD. During this period because of Turks, Pathans, Mughals, etc. invaders who came to plunder, spread religion or to rule over for short intervening periods, law and order in India was not proper and adequate. The Hindu rulers, more or less followed the laws prescribed by Manusmriti and Kautilya’s Arthashasthra, but the Muslim rulers who ruled with laws based on Koran, Hadis and Sara.11,13,14 During Mughal period, though the crimes and punishments remained same as in the past, unnatural sexual offences flourished more and execution by trampling under elephants feet or throwing to wild animals, were implemented in addition.3,5 The Portuguese, Dutch and French, though ruled India in 16th, 17th and 18th AD century respectively, it was the English East India Company not only settled but ultimately conquered the whole of India and introduced modern medicine and legal procedures mostly similar to the system prevalent in the British isles.13 Inquest by Coroner’s system was introduced in Calcutta (Kolkata) and Bombay (Mumbai) by Coroner’s Act, 1871 with Police system all over rest of the country. The first medical college of the country, Medical College of Calcutta commenced in the year 1835 and the first chair in Medical Jurisprudence was established in 1845 with Dr CTO Woodford as the first Professor of Medical Jurisprudence. The first postmortem in India was held by Dr Buckley in Madras (Chennai) in 1663 in a case of suspected Arsenic poisoning.10,12,13 The Indian Penal Code was promulgated by Act XIV of 1860 and thus codified various crimes 5

Part I: Introduction and Evolution

and punishments. The Criminal Procedure Code was enacted by the Act XXV of 1861 and Act VIII of 1869 streamlined the criminal procedures. Indian Evidence Act of 1872 also codified laws in respect of evidence in case of trials in the courts. After the independence in the year 1947, new amendments and statutes were added to these Acts. The terminology Medical Jurisprudence changed to Forensic Medicine after the independence. Dr Jaising P Modi was first Indian Physician who handled cases of medico-legal nature provided norms to suit the Indian atmosphere and conditions in crime investigation marking the definite role for doctors, which coined him, the title of Father of Indian Forensic Medicine. He also wrote the first Indian textbook Medical Jurisprudence and Toxicology. REFERENCES 1. Britain RP. Origin of Legal Medicine. Leges Barbarorum. Medicolegal Journal, 2003. Leges in Barbarorum (Germanic law), Encyclopædia Britannica, Retrieved on 29.12.2007: Source : http:/ /www.britannica.com/eb/topic-335008/Leges-Barbarorum. 2. Cameron JW. The Medicolegal Expert. Med Sci Law 1980;20(1):313. 3. Camps, Francis E (Eds). Gradwohl’s Legal Medicine, 3rd edn. Chicago: Year Book Medical Publishing Company, 1994. 4. Camps, Lucas, Robinson: Gradwhol’s Legal Medicine John Wright and Sons: Bristol, 1976. 5. Curran WJ. History and Development. In: Modern Legal Medicine, Psychiatry and Forensic Medicine WJ Curran, AL McCarry, LS Patty (Eds). FA Davis: Philadelphia, 1982.

6

6. Mathiharan K, Patnaik AK. Modi’s Medical Jurisprudence and Toxicology. 23rd edn. Lexis Nexis Butterworth 2005. 7. Butch Huston, Defining Death: A Report on the Medicolegal, and Ethical Issues in the Determination of Death. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Copyright Midwest Forensic Pathology® All Rights Reserved, Designed by Sandsharkdesigns, Washington DC, US Government Printing Office, 1981. 8. Vincent JM. Di Maio, Dominick J. Di Maio, Forensic Pathology, CRC Press, 2001. 9. Edinburgh A, C Black Encyclopaedia Britannica 9th edn. Vol XXI. Article: Salic law, 1886;214. 10. Franklin CA (Ed). Modi’s Medical Jurisprudence and Toxicology, NM Tripathi (P) Ltd: Mumbai, 1988. 11. Mukharjee JB. Forensic Medicine and Toxicology, Vol 1, 2nd edn, Arnold Associates: Kolkatta, 1994. 12. CK. Parikh. Parikh’s Textbook of Medical Jurisprudence and Toxicology for Classrooms and Courtrooms, 7th edn, CBS Publishers, New Delhi, 2001. 13. Rao NG. Forensic Medicine: Historical Perspectives, 3rd edn, HR Publication Aid: Manipal, 2002. 14. Rao SKR (Ed). Encyclopedia of Indian Medicine, Historical Perspective. Popular Prakashan, Mumbai 1985. 15. Simpson CK. The Changing Face of Forensic Medicine 1930-1960. Guy’s Hospital Report 1963;112:238-344. 16. Spitz WU, Fisher RS. Medicolegal Investigation of Death. Guidelines for the Application of Pathology to Crime Investigation. 3rd edn, Charles C. Thomas, Publisher. Springfield Illinois, 1993.

3

Doctor and the Law

INTRODUCTION As per existing practice, the law relating to criminal procedure applicable to all criminal proceedings in India (except Jammu and Kashmir) is contained in Criminal Procedure Code (CrPC) 1973, which came into force with effect from April 1st, 1974.14 The entire law is covered in 484 sections in two schedules. These two provide machinery for the punishment of offenders against the substantive criminal law of the land.5-7 It is a fact that the CrPC compliments Indian Penal Code (IPC) which defines the various offenses and provides the punishments. Further, though CrPC is procedural law, it covers many other matters. It deals with the constitution and structure of criminal courts, their classification and powers and prescribes the procedure for criminal proceedings.4,8-11 According to Mehta HS,12 law as laid down by the State and the Parliament is known as Codified Law or Statute Law. Besides this there are certain laws made by judges known as Common Law or Law of Torts, which includes certain wrongs or injuries caused by one man to another, which are usually not covered by statute law.4 COURTS IN INDIA Courts of Law in India are of two types:4 Civil Courts and Criminal Courts. Civil courts try only civil cases, whereas criminal courts try only criminal cases. The criminal courts further belong to different categories namely, Supreme Court, High Court, Sessions Court, and Magistrates Court. Recently, Government of India has set up certain Fast Track Courts for the speedy disposal of cases. These courts have the status of additional session courts.1,4,13 Supreme Court can try both civil and criminal cases. A medical man may be deposed in both civil and criminal courts, but mostly in the latter. The criminal courts and their powers are discussed in this chapter.1,3,5 Supreme Court Supreme Court is the highest judicial tribunal of the country and is located at New Delhi, the capital of India. Powers of Supreme Court: • It is a court of appeal. • It supervises and interprets law in the country. • The law declared by Supreme Court is binding on all other courts of the country. • It usually takes the cases referred from State High Courts. However, cases can also be filed directly in Supreme Court. • It can pass any sentence stated in law.

Chapter 3: Doctor and the Law

Part II: Medical Jurisprudence

High Court High Court is the highest judicial tribunal in the State and is located usually in the State Capital. However, some of the High Courts not located in the State Capital and they are: Kerala— Cochin, MP—Jabalpur, Assam—Guwhati, Orissa—Cuttack, and UP—Allahabad. Powers of High Court: • It is also a court of appeal. • It can take up all cases of criminal offenses. • It can pass all sentences authorised by the law. Session’s Court (District Session’s Court) This is the highest judicial tribunal for district and is located in the district head quarters. The court is presided over by the Sessions Judge, appointed by the High Court. High Court may also appoint Additional Sessions Judges and Assistant Sessions Judges to exercise jurisdiction in the court of sessions. Powers of Session Courts: • It takes up only the cases of criminal offenses referred by Magistrate’s courts. • It can pass all sentences authorised by the law; however, the death sentence passed by it has to be confirmed by the High Court. Magistrate’s Court Magistrate’s courts are criminal courts presided over by the Judicial/ Metropolitan Magistrates. In every district the State Government after consultation with High Court may establish as many of Courts of Judicial Magistrate as it may consider necessary. Depending on the revised set up of courts and allocation of magisterial functions, magistrates belong to two categories, namely judicial magistrates and executive magistrates (Fig. 3.1). The former are appointed by and are under the control of High Court, while the latter, as per CrPC, Section 20, are appointed by and are under the control of the State Government. Thus broadly speaking functions, which are essentially judicial in nature, are the concern of judicial magistrates, while the functions which are ‘police’ and administrative in nature are the concern of executive magistrates. Executive Magistrates As per section 20 CrPC, executive magistrate in a district could be – district magistrate, additional district magistrate (wherever necessary), subdivisional magistrate, or subordinate executive magistrate (Fig. 3.2).

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Part II: Medical Jurisprudence

Fig. 3.1: Different types of magistrates in general

Fig. 3.2: Different types of executive magistrates

The State Government if it thinks necessary may appoint special executive magistrate (section 21, CrPC). Executive magistrates are usually officers of revenue department, like District Collector, Subcollector or Tehsildar, and placed in charge of a district, subdivision or taluk and have all the powers of a district or subdivisional magistrate. Judicial Magistrates On the judicial side magistracy differs according to the population figures. Cities with a population of less than one million are considered nonmetropolitan cities, while those with more than one million are considered as metropolitan areas. According to

section 11, 12 CrPC, judicial magistrates in an order of hierarchy in a non-metropolitan area are (Fig. 3.3) Chief Judicial Magistrate, Additional Chief Judicial Magistrate, Subdivisional Judicial Magistrate, and Judicial Magistrate First Class. As per Section 13 CrPC the High Court in consultation with Central/State Government may appoint Special Judicial Magistrates. According to section 16, 17, CrPC, judicial magistrates in a metropolitan area in an order of hierarchy (Fig. 3.3) are—Chief Metropolitan Magistrate, Additional Chief Metropolitan Magistrate, and Special Metropolitan Magistrate. As per Section 18 CrPC the High Court in consultation with Central/State Government may appoint Special Metropolitan Magistrates also. Figure 3.3 highlights different types of magistrates empirical in India. Functions of Chief Judicial Magistrate (CJM)4 • CJM will be the chief of all other Judicial Magistrates in the district. • CJM will allocate work to different courts and supervise their functions in the district. • He can pass any sentence authorised by the law, except death sentence, sentence of life imprisonment or imprisonment for more than 7 years. The court of Chief Metropolitan Magistrate shall have the same powers as that of the Chief Judicial Magistrate. In addition he will exercise judicial powers within metropolitan area, over the port area of the town, over the limits of navigable rivers or waterways leading there to the town.2-4,12 Powers of Judicial Magistrates Powers of different judicial magistrates in order of their ranks are tabulated in Table 3.1. All magistrates are authorised to award twice the amount of imprisonment; he or she is permitted to order against two or more counts of offenses in one trial. But in no case one can be imprisoned for more than 14 years by any magistrate (Section 81, CrPC).4 Special Magistrate He or she could be a metropolitan, judicial or executive magistrate, appointed for special purposes, as for example to try cases of rioting when a number of people are arrested. They

Fig. 3.3: Types of judicial magistrates in general

8

Type of Magistrate

Death sentence

Imprisonment

Solitary confinement

Fine

Chief Judicial Magistrate (CJM) First Class Magistrate (JMFC)

No No

Up to 7 yr Up to 3 yr

Yes Yes

Any amount Rs. 5000

are also appointed whenever a regular magistrate cannot cope up with extra load of work or the enquiry has to be completed within a certain time limit. These magistrates could be of any class.4,13 Railway Magistrate: He or she will be of the rank of First Class Judicial Magistrate and is appointed to try cases of offenses under The Railway Act.1,4,13,14 Magistrate in Juvenile Court (Juvenile Magistrate): This is a principal magistrate/ a chief judicial magistrate and usually a woman and she presides over a Juvenile Court and tries juvenile offenders,15 who are children less than eighteen years of age (Juvenile Justice Act, 2000) and are accused of having committed a crime. These offenders are tried in juvenile courts under the Children Act, 1960, and if found guilty are usually not imprisoned or punished as an adult offender but, sent to a Child Reformation Centre called Borstal.1,4,14 Cases Tried by Judicial Magistrates All judicial magistrates can try cases such as:1,4,13,14 • Warrant case: It means a case relating to commission of a cognizable offense. Thus, a case which makes one liable for arrest without warrant, e.g. homicide, rape, etc. Such cases are usually instituted upon police report, but that can also be done on private complaint. • Summons case: It means that on cases of noncognizable offenses and being not a warrant case, a police officer has no authority to arrest without warrant. Usually, these cases are instituted on complaint and being simple case, punishment will usually be imprisonment of one year or less. Public Prosecutor He or she being a public servant under section 24 CrPC, is a legal expert, appointed by Central or State Government for conducting court prosecutions or other proceedings like appeal, etc. on behalf of the government. Doctors when summoned to give evidence can approach him/her for the case file or other such help. Public prosecutors could be of two ranks: Additional Public Prosecutor, and Assistant Public Prosecutor. Coroner’s Court Coroner’s Court is a court of inquiry and not court for trial presided by the officer appointed by the government, called Coroner.8,9,10,12 He is helped and assisted by some persons known as members of Jury. The jury consists of 5, 7, 9, 11, 13 or 15 persons (usually 7), who are men of education and of social position. This court existed in India at Mumbai and has been abolished in India since 1999.1,13,20 Duties and Powers of a Coroner Coroner is of the rank of First Class Judicial Magistrate, but he cannot pass a sentence. Various duties and powers of a coroner are enumerated below: • To hold inquiry in all cases of all unnatural or suspicious deaths, death of a prisoner, etc. dying within his jurisdiction. • To view the dead body and decide whether to hold an inquiry or not.

• He can order any medical man usually a Police Surgeon, to hold postmortem examination and to summon him to give evidence in his court. • He can also summon other persons as expert witness. • He can order for exhumation examination of a dead body for identification and for medicolegal postmortem examination. • When a verdict of foul play is established in his court, he can issue warrant for arrest of the accused person for trial in the Magistrate’s Court. If the accused cannot be identified, he usually returns an open verdict against this unknown person.

Chapter 3: Doctor and the Law

Table 3.1: Enumerating the powers of different types of magistrates

Open verdict: It means that the inquest is adjourned indefinitely due to want of information and could be reopened at any later date if further information becomes available. Indications • When cause of death is not found after autopsy due to putrefaction. • In cases of poisoning where evidence is not available to differentiate between accident and suicide. After the inquest, he forwards a copy to the Commissioner of Police. • He can grant remuneration to the medical man for attending the court for giving evidence. The fee offered is usually the traveling expense. • He can appoint a Deputy Coroner during his illness or unavoidable absence (it is a special power, which cannot be ordered, by a magistrate). Table 3.2 enumerates the differences between the coroner’s and magistrate’s courts.

Legal Sentences that can be Passed under Law As per Section 53, IPC, on conviction, criminals are punished by: • Death sentence, which is to be passed by court of sessions, subject to confirmation by High Court. • Life imprisonment is to be passed by court of sessions, the time usually comprises 20 years, which can be reduced to 14 years for good behaviour of the prisoner. • Imprisonment types: – Rigorous imprisonment with hard labour—all courts and First Class Magistrate can pass this order. – Simple imprisonment—all courts and magistrates can pass this order. – Solitary imprisonment—all courts and First Class Magistrates can pass this order. • Monetary fine: High Court and Sessions Court can impose any amount of fine. But First Class Magistrate and Second Class Magistrate cannot impose more than Rs. 5000/- and Rs. 1000/- respectively. • Attachment of movable property: This can be done by High Court, Sessions Court, and Chief Judicial/Metropolitan Magistrate as per court’s direction and power. • Detention in reformatories: This can be ordered by Chief Judicial Magistrate or Judicial Magistrate of Juvenile Court, where the offender is below 18 years and sent to Reformatory Centres/ Borstal Schools.14 • Usually court can order detention till rise of court for contempt of court.

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Part II: Medical Jurisprudence

Table 3.2: Differences between coroner’s and magistrate’s courts Coroner’s court •

It is only a court of inquiry.

Magistrate’s court • It is a court of trial.

•

The accused need not be present during the trial.

• The accused must be present during the trial.

•

Coroner has no power to award the punishment to the accused but can punish those guilty of contempt of court, e.g. nonattendance.

• The magistrate can impose fine and punishment as prescribed by the law to the accused as well to those guilty of contempt of court.

EXHUMATION Definition Exhumation is defined as a lawful disinterment or digging out of a buried dead body from the grave (Figs 3.4A to K) for medicolegal examination.1,3,7,8,11,18,20 Objectives Exhumation is done with definite objectives and basically they are: • Identification, i.e. confirming the individuality for civil or criminal purposes. • Autopsy with or without chemical examination of viscera in case of deaths, in which foul play is suspected. • Second autopsy, when the first autopsy report is ambiguous.

Procedures Exhumation is done under the order of appropriate officers, in the presence of a police officer, during daytime, preferably in the forenoon.3,5,12 1. District or Subdivisional Magistrates or Tehsildar are specially empowered to order for exhumation. Note: Police officer cannot order for exhumation. 2. Medical officer’s presence is required for doing the medicolegal postmortem examination, which may have to be done at the spot covered away from the public or in a close-by morgue. 3. The medical officer should preferably stand in the wind side of the body to avoid inhalation of gases.

Figs 3.4A to E: Exhumation procedures: (A) Identifying the grave, (B) Dug open grave exposing the body burried, (C) Dead body lifted up for postmortem examination, (D) Conducting the postmortem examination on exhumed cadaver, (Courtesy: Dr KWD Ravi Chandar, Professor and Head, Department of Forensic Medicine, Mysore Medical College, Mysore) (E) Killed by throttling and then attempted to conceal the crime by burning, failing which the body was burried. Exhumation ordered later, followed by autopsy, confirmed actual cause of death and crime

10

Chapter 3: Doctor and the Law Figs 3.4F to K: Exhumation procedure: (F) Identifying the grave, (G) Dug open grave exposing the coffin, (H) Coffin being lifted up, (I-J) Coffin opened with exposure of the dead body-putrefied, (K) Autopsy performed (Courtesy: Capt. Dr B Santha Kumar, Professor and Head, Department of Forensic Medicine, Govt. Stanley Medical College, Chennai)

Precautions at Exhumation • The grave is first identified and after the grave is dug, the undertaker identifies the coffin (Fig. 3.4A), if any. • The body has to be identified by as many persons as possible before sending for postmortem examination. • Following viscera and materials are sent for chemical analysis: – About 500 gm of soil from above, below and in actual contact with the body.

– – –

Hairs from head and pubic region. Nails, teeth and bones. Viscera such as liver, stomach and intestines.

Time Limit for Exhumation In India and England, there is no time limit but in countries like France, Scotland and Germany, etc. 10, 20, 30 years respectively are the time limits for exhumation. 11

Part II: Medical Jurisprudence 12

INQUEST Definition Inquest is defined as the preliminary inquiry into the cause of sudden, suspicious and unnatural death, which is apparently not due to natural causes. Explanation In case of unnatural deaths (Fig. 3.5), an urgent investigation into the cause of death is a must to apprehend and punish the

criminal. Thus, inquest is a judicial inquiry and the term “inquiry” means an action that extends to beyond what can be observed with person’s own eyes. Types of Inquest Globally, there are four types of inquests in practice and these are magistrate’s inquest, police inquest, coroner’s inquest and medical examiner’s system of inquest. Currently, in India only magistrate and police inquests are in practice. Medical examiner’s system is practiced in certain States of USA.

Fig. 3.5: Indications for inquest

Procurator Fiscal The procurator fiscal is a type of inquest, charged statutorily with the duty of making public enquiry into the causes of fatal accidents, and in special circumstances of sudden death in Scotland.17 Magistrate’s Inquest Magistrate’s inquest1,3,4,13,20 is an inquest conducted by a District Magistrate, Subdivisional Magistrate, and magistrate of the first class rank or any other magistrate as empowered by the State Government, such as Collector, Deputy Collector or Tehsildar (Executive Magistrates). Special Magistrate’s inquest1,3,4,13,20 are held in cases of: • Lock-up deaths • Deaths while under police interrogation • Deaths in prison • Deaths in police custody • Deaths due to police firing • Exhumation • Alleged dowry death • In all cases where the police normally conducts inquests, magistrate can hold an additional inquest, or in place of the police inquest. Places of Practice It is practiced throughout in India. However, it is not held routinely, but held only on special indications mentioned above. Note that in any case of unnatural death, magistrate may hold an inquest instead of or in addition to the police inquest. Police Inquest The inquest is held by police officer (called Investigating Officer) not below the rank of Senior Head Constable. Figure 3.5 illustrates indications for police/coroner’s inquest in India. Procedure • The police officer on receipt of information of death proceeds to the place of occurrence and holds an enquiry into the matter in presence of the inhabitants of the locality. • He then investigates the case and writes a report describing the appearance of the body wounds, stating how they were caused and by which weapon. • The witnesses are called panchas; panch (five) witnesses or panchayatdars will sign the same and the inquest report prepared so is known as a Panchnama. • If no foul play is suspected, the dead body is released to the legal heirs of the deceased for the purpose of cremation and disposal. • In suspicious cases, bodies are sent for postmortem examination to the Government Medical Officer or an authorised forensic/ medicolegal expert, employed in a private medical college. Postmortem Reports These are documentary evidence, always written by the doctor who has done the autopsy, in prescribed forms, in triplicates, to be served as mentioned below: • The first copy is sent to the investigating officer, through an authorised constable who collects the same.

• The second copy is sent to the Police Superintendent or Magistrate of the area in a sealed cover. • The third copy is filed in the office files for further reference. Note: In private medical colleges where only the qualified forensic experts are allowed to do the medicolegal autopsies, the report must be forwarded to investigating officer through the Head of the Department of Forensic Medicine. Place of Practice Police inquest is practiced throughout India. Medical Examiner’s System Medical examiner’s inquest is a type of inquest held by medical practitioner.16,18-20

Chapter 3: Doctor and the Law

Each of these, except Coroner’s system is discussed individually. Figure 3.5 illustrates the various indications for inquest in Indian circumstances.

Procedure • A medical practitioner known as Medical Examiner is appointed to perform the functions of coroner. • He has no authority to order arrest of any person. • He has to visit the scene of crime and conduct the inquest and also the postmortem examination. Hence, this is considered superior to any other system of inquest. • Medical examiners system of inquest is not practiced in India. It is held in most of the parts of United States of America. COURT PROCEDURES IN CRIMINAL COURTS There are several court procedures, which a doctor may have to know in attending the criminal court and tender his evidence1,7,8,13,14,18,20 and they are: • Attendance in court • Subpoena (summons) • Warrant • Conduct money • Oath taking • Recording of evidence. Attendance in Court Most of the medical reports/medical certificates are not acceptable in the court of law, unless testified in the presence of the accused. Thus, the medical officer as an expert witness will have to attend the court on a particular day, during the trial, for deposition and cross-examination of the contents in the report issued by him to the court. Subpoena (Summons) Definition Subpoena is defined as a document compelling the attendance of a witness on a particular day and time in the court of law under penalty. Explanation Subpoena is a written document issued in duplicate by the presiding officer of the court with proper seal and signature, to be served to the witness demanding his/her presence in court punctually on the specified date and time for giving evidence in connection with a particular case and with warning to not to be absent without prior permission of the court. It can be served also to produce any official document or any paper before the court of law (Box 3.1A). However, summons is a milder form of process. Procedure of Serving the Summons Usually, it is issued by presiding officer of the court, delivered by a court official or a police constable. Person receiving should sign on the original and keep the duplicate with him.

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Part II: Medical Jurisprudence

Box 3.1A: Copy of summons issued by the court of law in Karnataka State, India

Govt. of Karnataka FORM No. 33 SUMMONS TO WITNESS (See Sections 61 & 244) To WHEREAS complaint has been made before me that (name of the accused) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . of (address) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . or is suspected to have committed the offense of (State the offense concisely with time and place). . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and it appears to me that you are likely to give material evidence or to produce any document or other thing for the prosecution. You are hereby summoned to appear before this court on the day.....next at Ten O’clock in this forenoon, to produce such document or thing or to testify what you know concerning the matter of the said complaint and not do depart hence without leave of the court; and you are hereby warned that, if you shall without just excuse neglect or refuse to appear on the said date, a warrant will be issued to compel your attandance. Dated, this . . . . . . . . . . . . . . . . . . . . day of . . . . . . . . . . . . . . . . . . . . . . . . 201 . . . . . Seal of the Court

If person summoned to is not available, it may be served to: • The other major member of the family/ relatives, but not to a servant. • If the person is a government servant, it may be served through the head of the office in which he or she is employed. • It may be even affixed on some conspicuous part of the house in which the person summoned ordinarily resides. • Summons by post: It can even be sent by registered post. However, on these occasions, court may not consider this as being served. If the postal authority returns the cover stating he or she is refusing to receive the same, court considers that it has been served in spite of not receiving it. Rules of Summons If a medical officer is summoned to attend two courts on a particular time and day, following rules may be opted: • Criminal cases should be given preference over civil cases. • If both are criminal cases, higher courts should be given first preference. However, the medical officer should inform the other court which he or she is not attending. • If both cases are of the same ranking courts, summons received earlier should be attended first. • Noncompliance to summons in a civil case, may render one liable to action for damages, but in a criminal case, fine or even imprisonment (unless some satisfactory excuse is given) may be ordered. • He or she cannot leave the court without the permission of the magistrate or the judge. • If he or she fails to attend summons in time, a warrant can be issued to compel his or her attendance.4,13,14 • An attendance certificate (Box 3.1B) will be issued by the court on demand. 14

Signature

Warrant (Witness Warrant) Definition Warrant is an authority under the seal and signature of the presiding officer of a court to a person to be arrested and produced before the court to be dealt with according to law. It is a written order from a court, commanding police to perform specified acts/ arrests to produce the witness in court of law. Types Warrant could be bailable warrant (BW) or non-bailable warrant (NBW), issued through police by a court to compel attendance of the witness in court on a fixed date.3,4,12,13 A court may issue this in lieu of or in addition to summons for appearance in the court for following reasons: • If there is reason to believe that he or she will abscond or will not obey the summons. • If witness has failed to appear before without prior reasonable excuse, though clearly served with summons. • In a case of breach of bond of security for appearing (vide section 90 CrPC). Conduct Money Definition Conduct money is the fee offered to a witness in civil case, at the time of serving of summons to cover the travelling expenses for attending the court. In the civil cases: A Government Medical Officer gets the conduct money when he or she serves a summons. In the criminal cases: Where state is the prosecuting party, Government Medical Officer will not get conduct money, but as per law (Section 312 CrPC), he or she will be paid the travel allowances (TA) by the court. This is also called Witness

Chapter 3: Doctor and the Law

Box 3.1B: Copy of certificate of attendance issued on attending summons issued by the court of law in Karnataka State, India

CrI. R.P. 68

Govt. of Karnataka CERTIFICATE OF ATTENDANCE

Form No. 15 (Criminal) Certificate of Attendance Certified that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . appeared before me as a witness on behalf of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . in Session’s Criminal Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . on the file of this Court for . . . . . . . . . . . days from. . . . . . . . . . . . . . . . . .. to. . . . . . . . . . . . . . in this official capacity to dispose the facts within his knowledge and that he has been paid the undermentioned allowances Rs. P Travelling Allowance

..

Subsistance Allowance

..

Total

..

Court of the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 . . . . . Judge/Magistrate

Bata.1,4,10,13 In a private criminal case, Government Medical Officers will get fee, private practitioners will get fee from the state or the private party concerned. Oath Taking Before deposition of evidence begins, witness must take an oath or affirmation. Unoathed evidence is not admissible to the court of law, except when a person is below 7 years of age.18,20 Oath The witness is to take oath by reading or quoting the following with the help of bench clerk: • I swear before Almighty God that the evidence I shall give to the court, touching the matter in question, shall be truth, the whole truth and nothing but truth. • The evidence which I shall give to the court shall be truth, the whole truth and nothing but truth. So help me God (Indian Court of Law).2,4 • I swear to tell the truth, the whole truth, and nothing but truth, so help me God. If witness desires to give his evidence on solemn affirmation he or she will take oath by saying: • I solemnly affirm that the evidence I shall give to the court, touching the matter in question, shall be truth, the whole truth and nothing but truth. • I solemnly affirm that the evidence which I shall give to the court shall be truth, the whole truth and nothing but truth.2,4 • I solemnly affirm, to the truth, the whole truth, and nothing but truth (USA Court of Law Oath).16 As per section 191, IPC, a witness who willfully makes a false statement after taking oath is considered as guilty of crime of perjury (giving false evidence under oath) and may be prosecuted. Punishment for perjury is dealt with as per section 193, IPC.

Recording of Evidence After taking the oath, the recording of evidence will be done by following (Fig. 3.6) four steps:1-8,10,13,14,18,20 1. Examination-in-chief 2. Crossexamination 3. Re-examination 4. Court questions. Figure 3.7, provides a bird’s eye view of court scene in the form a sketch for familiarising the court, providing the place/ locations of various court officials, public prosecutor, defense counsel (lawyer), witness (doctor), accused (criminal), judge/ magistrate/court presiding officer, court audiance, etc. This figure will be of great help to every doctor who is a beginer visiting the court as witness for first time. Examination-in-chief • This is done by prosecution side, i.e. by the public prosecutor in State cases or by the lawyer engaged by the prosecution side in private cases. In other words here the party who calls to give evidence in the court examines the witness. In criminal cases the public prosecutor does it, while in civil cases, the pleader of the party who cited him as a witness does it. The objective of this examination is to bring out the facts of the case known to the witness concerning the case. • At this stage, the questions which are put to the witness and answers elicited, are both recorded by the court. Here, witness is to relate the facts fully within his or her knowledge regarding the case. • But if the Judge is convinced that the witness is hostile (refer page 28), leading questions may be allowed by him. • Usually, no leading questions are allowed during examination-in-chief. However, according to Prof JB Mukharji, they are allowed with the permission of the court under following circumstances:18

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Part II: Medical Jurisprudence

Examination-in-chief (By public prosecutor) Q. “Doctor, what precautions are necessary before injecting penicillin?” A. “A sensitivity test should be done”

Cross-examination (By defense counsel/lawyer) Q. “Doctor, is it possible that an anaphylactic reaction may still occur even though the sensitivity test is negative?” A. “Yes”

Re-examination (By public prosecutor) Q. “Doctor, what would be the difference in the anaphylactic reaction in a case where the test was positive and another case in which it was negative?:” A. “In the former case, it would be far more severe; in the latter case, it would be mild.”

Court questions (By presiding officer/magistrate/judge) Q. “Doctor, is there no way by which one can be absolutely certain if the patient is sensitive to penicillin or not?” A. No.

Fig. 3.6: Recording of evidence in court of law. (Note—Doctor as witness-in the witness box) (Courtesy: All performers are students of Meenakshi Medical College and Research Institute, Kanchipuram, Tamil Nadu at the under graduate Convention and Mock Trial Contest of CME in Basic Law and Ethics organised by the Department of Forensic Medicine 4-6 April 2007, on behalf of National Foundation of Clinical Forensic Medicine)

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Chapter 3: Doctor and the Law Fig. 3.7: Photographs and sketch presenting bird’s eye view of sessions courts in India: A—Presiding officer/Judge/Magistrate; B—Court stenographer; C—Bench clerk, D—Defense lawyer; E—Public prosecutor; F—Doctor (witness box, usually on the left side of the presiding officer); G—Waiting place for other expert witnesses arrived on summons; H—Criminal in custody; I—Police constable; J—Court announcer; K—Court audience (Photographs by Dr Ritesh G, Manager, Assoc. Professor of Forensic Medicine; KMC, Mangalore, Karnataka)

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Part II: Medical Jurisprudence

– – – – –

While making introductory remarks/ presenting undisputed matters (example: when the name, occupation, etc. of the witness are asked). While presenting identification facts – when attention of witness is drawn for identifying person/thing. To assert memory. While giving contradictions. When a witness is declared as hostile witness.

Leading Questions Definition: Leading questions are those questions, which suggest their own answers conclusively, may be by a simple ‘yes’ or ‘no’, or the answer wished for, e.g.: Routinely to a witness who had seen Mr A (accused) hitting Mr B (victim) by an iron bar on Sunday evening at 6 pm, the question asked will be: • Where had you been at that time? • What did you see? • With what object did Mr A hit? Etc. However, when the witness becomes hostile, questions become leading questions and will be asked as follows: On Sunday, 6 pm evening did you see Mr A hit Mr B by iron bar? Cross-examination The lawyer of the opposite party, i.e. defense lawyer, conducts the cross-examination. He or she will always try to weaken the evidence given by the witness during examination-in-chief and try to prove before the court that the evidence given is untrustworthy and unbelievable. In this stage, leading questions are allowed. During this stage of cross-examination, witness must be very careful and should not answer the question, if he or she does not understand it properly. There is no time limit for a cross-examination. It may last for hours or even days. The judge or the magistrate may disallow irrelevant questions (section 152 IEA) and cut short the cross-examination. Note: French law takes a person to be always accused, where as in English and Indian law a person is to be proved an accused (benefit of doubt is given to the person accused; the person is innocent, till otherwise proved). Re-examination The prosecution side (Public prosecutor) does this, in order to clear up certain ambiguities or discrepancies that might have been made by the witness in the cross-examination. However, no question relating to new matters, are to be asked (without the permission of the court). If new matters are asked, the defense will take another chance of cross-examination.

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Court Questions The judge/magistrate/jury can ask any question to the witness during any stage of trial in order to clarify certain facts/findings of case. The evidence thus recorded by presiding officer - judge/ magistrate should be next given to the witness for his signature, should be read fully by the witness, and signed. If there are any corrections in the evidence recorded, all typographic errors must be corrected and got signed by the presiding officer of the court. The witness is liable to be called again, if necessary, if further evidence is needed.

MEDICAL EVIDENCE Medical evidence could be in two1,11,13,14,18,20,23 forms, namely— Documentary evidence and Oral evidence. Documentary Evidence These are again of several types and following constitute few examples: • Medical certificates for ill health, insanity, death, etc. • Medicolegal reports such as injury report, postmortem report, age report, reports on sexual offenses like rape. • Dying declaration and dying deposition. Medical Certificates Medical certificates are documents issued by a doctor only after confirming for what reasons it is being issued. It usually consists of three parts: 1. Date, time and place of examination. 2. Name, age, sex of the person to be examined with his/her signature and two identification marks. 3. Final opinion: Include number of days of rest/such other advices given with reasoning. Name, Signature, Designation, Medical Council Registration Number, and address of the doctor with rubber stamp/seal should follow it. Death Certificate Death certificate must be issued in a specified manner, as suggested by the World Health Organisation (WHO format) mentioning facts like name, age, sex, address, cause of death, etc. Death certificate should be withheld if there is any suspicion of foul play.11,20 Medicolegal Reports Medicolegal reports are documents prepared by the Medical Officers after being asked or ordered by the Police Officer or Magistrate. They are often related to criminal cases and should include four parts:11,20 • Preamble: Date, place and time of examination including name, age, sex, signature/left thumb fingerprint, two identification marks, consent, etc. of the person to be examined. • Reasoning part: Facts observed on examination. • Opinion: The inference drawn from facts. • Concluding part: Name and signature, designation, registration number, address of the doctor certifying, with his/her rubber stamp/seal. A medicolegal report may not be admitted as evidence unless the doctor attends the court and testifies the facts under oath. Defense Council can also cross-examine the doctor over the report. Dying Declaration Definition Dying declaration is a statement, verbal or written (or even by gestures) made by a deceased person before his/her death, relating to the circumstances leading to death. Explanation Dying declaration should fulfill following ingredients: • Person making the statement is likely to die. • Statement must be made as to the cause of his/her death or the circumstances resulting in his/her death. • The cause and manner of his/her death must be in question. • Statement must be complete. • Declarant must be of competent mental state to make the statement.

Medicolegal Importance • Admissibility of dying declaration is limited to criminal cases where the cause of death is being inquired into (manslaughter) • In English Law, dying declaration is only admissible if the person is in full possession of his/her senses and believes that his/her recovery is impossible and death is imminent— the legal assumption being an individual would speak nothing but truth during the last moments of his/her life. • All dying declarations are not exclusively taken into consideration to judge the guilty. • All courts base their judgment on the circumstances of the individual case. • If the victim does not die, then the dying declaration is void and the victim has to testify in the court. Dying Deposition Dying deposition is almost a dying declaration. The main difference being that it is always recorded by a magistrate in presence of the accused or his/her lawyer. Legally, the dying deposition is more valuable than dying declaration as the accused has got the opportunity to challenge and cross-examine. The Medical Officer’s presence is not indispensable, but he/she may

have to certify the mental fitness of the patient. Table 3.3 gives differences between them. However, currently this is not in practice in India. Oral Evidence Oral evidence is always superior to documentary evidence in trial for the reasons that, the person has to prove on oath that the evidence is true and is cross-examined. However, a person giving documentary evidence is also supposed to do the same, exceptions being: • Dying declaration. • Printed opinion of experts in the form of textbooks, when author is either dead or stays at a very distant place, and to bring him/her would mean unnecessary loss of time and money. • Evidence previously given in a judicial procedure. • Deposition of a medical witness in a lower court, attested by the magistrate. • Chemical examiner’s report is sufficient and his/her personal attendance is usually not necessary. All these documentary evidences are accepted by court as unsworn documents, without any oral testimony.

Chapter 3: Doctor and the Law

Procedure Following steps must be observed and taken care of: • As soon as the severely injured person is brought to a hospital casualty, it is the duty of the medical officer to inform the magistrate to have a dying declaration recorded. • If the doctor thinks that the patient will not survive till the arrival of the magistrate, he/she can record the same himself or herself. • The treatment should not be delayed or avoided while recording dying declaration. • The major role the doctor has to play and help the magistrate in recording the dying declaration is that he/she should determine the condition of the patient and assess whether the dying person is mentally sound (compos mentis). • If the declarant dies or becomes unconscious while recording, the doctor should record the information obtained up to the point. • It is usually recorded in forms of questions and answers without prompting (best in patient’s own words). • It should be recorded in the identical words of the patient in his/her own vernacular. • No suggestions or leading questions are allowed. • No outsider is allowed to be present. • After completion of writing, it is read over to the patient who has to approve the same by his/her signature on the same or if illiterate by taking his/her left hand thumb impression, inserted as proof of approval. Signature of two witnesses is mandatory. Even if doctor records it, witnesses must also sign the same. It is then dispatched to the court for official use.

Types of Oral Evidence Types of oral evidence could be of two types: 1. Direct: Refers to facts, which are seen, heard or perceived by any other sense. 2. Circumstantial: It proves one or more of the subsidiary circumstances or associated events. WITNESS Definition Witness is defined as a person who provides evidence about a fact in the court of law under oath and being summoned to court to attend without failure and under penalty. Classification Witnesses are classified into following types: Common Witness Common witness is that person, who narrates what he/she has heard or perceived or states the facts observed by him/her. Expert Witness Expert witness on account of his/her special professional training and skill, is capable of giving opinion or deducing inferences from the facts observed by himself or by others, i.e. Medical Men, Chemical Examiner, Fingerprint Expert, Handwriting Expert, Ballistic Expert, etc. Medical Man (Doctor) A medical witness is generally considered as both common and expert witness. • Common because he/she can say the size, positions and number of wounds, etc.

Table 3.3: The differences between dying declaration and dying deposition Criteria

Dying declaration

Dying deposition

Made to Oath Presence of accused/his lawyer Cross-examination Legal value

Medical officer/ Magistrate Not necessary Not needed Is not possible Less

Magistrate only Necessary Allowed Permitted More

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Part II: Medical Jurisprudence 20

• Expert, because he/she can say with certainty whether the wound is antemortem or postmortem; accidental, homicidal or suicidal; age of wounds; and can give opinion about the cause of death. Tips to the Expert Witness Forensic practitioner is often called to court to testify as an expert witness. The following are some guidelines for effective expert witness testimony: • Before going to court – Keep thorough notes, records, photos, diagrams, etc. – Carefully prepare your reports and consider appropriate language, completeness and opinions. – Prepare your prosecutor, public prosecutor (PP), assistant public prosecutor (APP) with a pretrial conference. – Review the case before you enter the courtroom. – Never allow a prosecutor or defense lawyer to push you beyond your area of expertise on opinion. Ask yourself, “can my testimony withstand the evaluation of a competent opposing expert”. • Giving expert testimony – Wear conservative clothing. Avoid wearing lapel pins or jewelry, which designate membership in a club, group, or religion. – When answering questions, respond to the judges/ magistrate, not the lawyer. Talk to the judge/magistrate and make eye contact. – Pause before giving your answer. Give the opposing counsel a chance to object. Also, consider what you are going to say. – Try to avoid ‘ums..’ and ‘ahs..’ when speaking. – Present a professional demeanor. It is not only important what you say, but how you say it and how you look saying it. – Be aware of your physical presence—how you stand and your body language. Don’t fumble with exhibits or props; watch out for change in pockets. – Don’t fidget or sway when standing. – Watch your demeanor. Don’t appear too confident (it may be construed as arrogance). – Avoid animosity. Appear sincere, objective, polite and fair. Concede, if you don’t know the answer. – Express your opinions with emphasis. Educate using no technical language. Make your testimony interesting. – Concentrate: listen to every word of counsel. Don’t ‘jump the gun’ with your replies. – Pause to clarify concepts. – Remember: a court clerk is recording everything you say. Be specific when giving your testimony. – Respond directly to the question being asked. • Cross-examination – You do not have to answer any question ‘yes’ or ‘no’. Explain your rationale. – Be careful with questions such as. ‘Is it possible that…?’ or ‘Is it fair to say…?’ – It is acceptable to say, ‘I don’t believe, I am qualified to answer that question’ – Listen to all aspects of the hypothetical question. If you are unsure what the lawyer means, ask for a clarification. – If you are not given a chance to explain your answer, ask if you can respond to clarify your statement. – Remember your demeanor and attitude. You are not supposed to take sides.

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The louder and more belligerent the lawyer becomes, the more composed and polite you should become. Don’t lose your temper, be cool. – If you are asked a particularly lengthy, confusing question simply say, ‘I don’t understand your question, could you rephrase it?’ • Other points – Speak in a manner that lay people can understand. Avoid jargon, especially ‘Scientifics’. – Go over prior testimony, reports, and exhibits before the trial. Try to have a pretrial conference with the prosecutor. – Be objective. You are not an advocate. It should not matter to you whether the case results in a guilty or not guilty verdict. Your job it to be an advocate for your opinion. – Use visual aids, analogies, illustrations from everyday life, and the chalkboard. – Pay attention to the judge/magistrate. ‘Objection sustained’ means you cannot answer the previous question. – Do not box yourself into a corner. Beware of questions like, ‘Have you ever made a mistake?’ and ‘Is not it possible…’ – Don’t try to ‘weasel out’ of a difficult question. – Be aware of the cross-examination trick of taking an excerpt from a publication out of context or an excerpt from a non-existent article. You can always ask the lawyer to show you the article to refresh your memory or even to read it out. – Be able to say: ‘I don’t know’ or ‘I was wrong’. – Take the lead to meet with and talk with counsel. – Mentor new, inexperienced prosecutors. If he/she is new or inexperienced in a given area, be patient and offer your assistance as an expert. Try to remember how you felt the first few times you appeared in court. Skilled or Scientific Witness Skilled or scientific witness is one, who has specialised knowledge of technical subjects. He/she may be expert but usually he/she has no first hand knowledge of the particular case. Two Other Types of Witness Two other types of witness hostile witness and unfavourable witness are often encountered in legal practice. These are independent witness who make contradictory statements and the prosecution itself can cross-examine them with permission of the court during trial. However, question of value of their evidence usually arises.13,21,22 Hostile Witness When a witness makes statements against the interest of the party who has called him/her, he/she is declared as a hostile witness.13 A hostile witness is thus described as one who is not desirous of telling the truth at the instance of the party calling him/her. Unfavourable Witness The unfavourable witness is one called by a party to prove a particular fact, but fails to prove such fact or proves an opposite fact.22 This makes it necessary that he/she should be cross-examined by the very party who has called him so as to demolish his/ her stand. Under Section 142 (IEA) the court can grant permission for asking leading questions and under Section 154

The Behaviour of a Doctor in Court (Rules/Conduct and Duties of a Doctor in a Witness Box) Medical witness must maintain certain principles listed below: • Study and master the facts of the case before attending the court. Study recent aspects on it. • Attend the court promptly and punctually, dressed decently, consistent for the dignity as a doctor. • Doctor, while entering as well as leaving the court room should show his respect to the presiding officer by bowing down or joining hands and also use the word Your honour while addressing him/her. • Usually, as a rule, doctor’s evidence is taken soon after his/ her arrival as the court relishes his/her importance for time and duty. However, if there is any delay, he/she can politely inform the public prosecutor that he/she is waiting. • Avoid unnecessary talking about the case with anyone else while in court premises. • Speak slowly, but loudly and distinctly. • Use plain language, avoiding superlatives or exageration and technical terms as far as practicable. • Do not lose temper in a court, because lawyer will try to make you do such. If you do not know a thing, say it plainly. Sometimes, the defense lawyer quotes a passage from a book and you are asked to give your opinion. Do not give opinion unless you yourself read the whole passage, when it may give a totally different meaning. • Avoid long discussions and theoretical arguments in a court. Answers if possible, should be brief and to the point. • Volunteering statement: A witness is not supposed to volunteer his/her statement in a court, unless called for to do so. This may be true, when the witness is a layman, but not so in case of a medical witness. Though a medical witness is called upon by one side to give evidence in the court, he/she must not forget about honesty and fair dealings, his duties to the opposite party. He must remember that he/ she must help the court with his/her special knowledge to elicit the truth. Hence, if he/she thinks the court should be appraised of some facts, which have not been asked from him, he should volunteer his statements. DOCTOR AND SCENE OF CRIME1-3,7-8,11,14,20,24 The term scene of crime is the place of any suspicious or unnatural death. It is important that all these need an open minded approach along with a good observational capacity and patience. Here the satisfactory outcome basically depends upon the combined efforts made by the various team members and experts visiting the scene. Among these, role of a doctor (medicolegal expert/forensic physician/forensic pathologist) is essential. Ideally speaking, police must invite this doctor to the scene immediately prior to the disturbance of scene or before natural changes in the dead body take place, allowing an expert to comment on time since death and cause of death. However, it is not surprising that the police rarely involves a forensic pathologist in crime scene examination. There are also several occasions when pathologist cannot attend while the body is still at scene. It is still beneficial for the pathologist to go and visit the scene of crime which will help him to obtain assistance in interpretation of the case. Retrospective visit to the actual site and examination of scene might be helpful in deciding certain road traffic accident cases or such other cases. Usually, removal of the body from crime scene is done by the police. Body can

be wrapped in a sheet of plastic material avoiding any contamination by foreign material during removal or shifting. It is suggested that every doctor who is involved in crime scene visit/examination must carry a Crime Scene Examination Kit of his own and it should include special equipments of his choice, such as: • Hand lens for examining injuries • A measuring tape and ruler • Autopsy instruments • Personal camera for the record of features of your own interest • Clean containers (glass/plastic) with proper fitting stoppers/ lids and paper/polythene envelops with labels, rubber gloves, swabs, glass slides, etc. • Suitable thermometer for recording rectal temperature/ atmospheric temperatures. CONDUCT AT THE SCENE On receiving call from investigating officer (IO), the doctor should report to the scene of crime punctually prior to any interference. At the outset he should make note of the posture, clothing and other features of the body and surroundings. Do not alter the position of the deceased. Always describe things in detail prior to their being picked up or even before touching and examining them. Never make hasty opinions or conclusions. Leave the place only after you have finished your examination completely. Enumerated below are certain points of medicolegal concern which a doctor cannot afford to miss and they are described as follows: • Prepare notes—On the position of the deceased, highlighting the details about things around. • Always draw a sketch of the scene mentioning relevant measurements – Sketch is usually helpful in refreshing the memory of the officer and help in establishing the bonafide nature. It would also help in arguing out and establishing the case in absence of photographs. Include particulars about the surroundings around the dead body, covering about the walls, floorings, furniture, doors and windows, fixtures, fittings, etc. • Photographs may be taken along with. Always remember ‘A picture is worth a thousand words’. • Use handlens, U-V lamp, etc, as they are not only essential, but are also of great help in visualising certain things in detail. • Collect all the trace evidence materials such as smears and stains of blood, mud, semen, saliva, or any other material, or any poison. These are to be collected for referring to FSL for further examination. • Collect empty/partly full or partially empty containers—if any. If suspected of containing harmful materials they are noted and collected for further analysis. • Clothing of the body – look for whether it is normal or disturbed, deranged, such as lifted up skirt with pulled down panties, or unhooked or torn buttons of a blouse or brassieres. They are common in a sexual offence case. • Tear in the dress worn may also be important to note as it may correspond to the stab wound or firearm wound, etc. • Blood at the scene—following should be noted: – The amount of blood shed: Dural sinus / major neck veins such as jugulars, usually shed excessive blood, if torn. – The distribution of blood: Here look, whether there is a large pool of blood near the body or just a trail of small splashes or drops. Assess whether it spurted from the victim or had flown out in slow stream or fallen drop by drop, etc.

Chapter 3: Doctor and the Law

(IEA) for cross-examining the party’s own witness which is wholly left to the discretion of court.

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Part II: Medical Jurisprudence 22

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The shape of splashes, drops or smears: Better record them as noticed. – Blood and its location: Blood stains may be seen on the wall, furniture, and ceiling or on any other objects in the room, suggestive of arterial spurting from small or medium sized artery, e.g. radial artery at the wrist. Venous bleeding is slow steady flow, which can produce a pool of blood if the victim is at rest and separate drops, more widely spaced suggest that victim was live for sometime and ambulant after the injury. – Bloodstains and its shapes: Spurts of blood on flat vertical surfaces, e.g. a wall, can produce a series of linear streaks looking like inverted exclamatory marks. Single drops from a vein, differ in appearance according to angle at which the drops fall on a flat surface. – The skin ridge impressions in smears: Fingerprint experts could be of help. – The relation of the blood to the body: Pooling of blood under the dead body suggests lack of mobility change in position of the body after death. – Presence of drag marks of blood under the body: Suggests exact scene of assault and death. Blood trail in the scene indicates that victim received wounds at a distance from place where body was found. – Blood and resembling material stains: Paint, dye, jam, sauce, tomato ketchup, pan spitting, etc. resemble fresh blood, and can be readily misleading. Rust and tar stains are not easily distinguished from dried bloodstains and need expert examination opinions. – Photograph of bloodstain: This is certainly useful, but photography should be in colour. • Seminal stains—may be noticed on the clothing worn by the victim or may be seen at the scene on some other objects like bedsheets, undergarments, handkerchief, in the waste paper basket, used to wipe off the genitalia and then discarded, etc. Mention must be also made about the relationship of these stains to the body in order to correlate or explain the crime. • Postmortem hypostasis—distribution, colour, and fixing of postmortem hypostasis needs careful study and reporting. Its distribution indicates the position of the dead body after death. For example, stain will be seen in lower extremities, external genitalia, and lower part of the forearms of the dead body found in hanging position. Likewise colour of postmortem lividity can draw attention in poisoning cases, e.g. CO poisoning renders cherry red colouration to the lividity. Thus, lividity can give clue accordingly to the cause of death as well. • Hairs or fibres at the scene–hairs can be the only clue to the crime happened. Hairs can provide crucial information about the criminal when properly identified. Hence, if hairs are noticed at the scene they must be collected and preserved for further examination at FSL.

• Importance of good illumination–scene always must be examined in proper illumination, with accessories such as handlens, UV light, etc. REFERENCES 1. Rao NG. Legal Procedures for Medical Doctors, 2nd edn. HR Publication Aid, Manipal, India, 2002. 2. Mathiharan K, Patnaik AK. Modi’s Medical Jurisprudence and Toxicology. 23rd edn. Lexis Nexis Butterworth’s. 2005 3. Dogra TD, Lt Col. Abhijith Rudra (Eds). Lyon’s Medical Jurisprudence and Toxicology for India, Delhi Law House New Delhi (India), 11th edn, 2005. 4. Ratanlal and Dhirajlal’s—The Code of Criminal Procedure, 18th edn. Wadhwa and Company, Nagpur, 2006. 5. Dikshit PC (Ed). HWV Cox, Medical Jurisprudence and Toxicology, 7th edn. Lexis Nexis Butterworths, 2002. 6. Lyon, Commentary on Medical Jurisprudence for India, 10th edn, 2002. 7. Nandy A. Principles of Forensic Medicine. New Central Book Agency, Kolkata, 2000. 8. Parikh CK. Parikh’s Textbook of Medical Jurisprudence and Toxicology for Classrooms and Courtrooms, 7th edn, 2001. 9. Patil S Hemalatha. The Coroner (1st edn), NM Tripathi Pvt Ltd: Mumbai, 1989. 10. Salwan SL, Narang U. Academic’s Legal Dictionary, (9th edn), Academic (India) Publishers: New Delhi, 1994. 11. Rao NG. Practical Forensic Medicine, 3rd edn. Jaypee Brothers Medical Publishers, New Delhi, 2007. 12. Mehta HS. Medical Law and Ethics in India, 1st edn. The Bombay Samachar Pvt. Ltd., 1963. 13. Rao NG. Legal Procedure and Ethics for Doctors, 2nd edn. HR Publication Aid, Manipal, 2002. 14. Singh Avtar, Principles of Law of Evidence, 10th edn. Central Law Publication, Allahabad, India, 1996. 15. The Juvenile Justice (Care and Protection of Children) Act, 2000 (30 Dec. 2000) (Short Notes) Choudhary Publications, Meerut, India, 2000. 16. Fisher B AJ, Expert Witness Tips, in Techniques of Crime Scene Investigation, 6th edn, 2001. 17. Vanessa, Churchill’s Medicolegal Pocketbook. Churchill Livingston, London, 2003. 18. Mukherjee JB. Textbook of Forensic Medicine and Toxicology, Vol 1, 2nd edn, 1994. 19. Davis JH. The Future of Medical Examiner System. Am J Forensic Med. Pathol 1995;16:265–69. 20. Rao NG. Principle and Practice of Forensic Medicine, HR Publication Aid, Manipal, India, 2002. 21. Singh KK. The Indian Evidence Act, 1872, 2nd edn. Eastern Book Company, India, 1980. 22. Cross-on Evidence, 4th edn, 220, quoted from Stephens’s Digest of the Law of Evidence, cited in Sigh Avtar, Principle of Law of Evidence, 10th edn. Central Law Publication, Allahabad, India, 1996. 23. Chandran MR (Ed). Guharaj Forensic Medicine, 2nd edn. Orient Longman, Hyderabad, 2004. 24. Murty OP. Scene Investigation, Noncommercial Academic Publication, 1st edn, 1999;19-22.

INTRODUCTION Ethics is a science of moral values or principles. Medical ethics is thus described as moral principles (code of conduct), which should guide the members of medical profession in their dealings with the patients, their relatives, community, and with other colleagues in profession. The principle objective of the medical profession is to render service to humanity with full respect for dignity of human beings. Every doctor, whatever is his/her speciality, has to discharge medicolegal responsibilities and to solve medicolegal problems from the very first day of his/her medical practice. Almost everything a doctor does in practice of medicine is in some manner or the other is governed by the legal system. Quite often, a doctor victimizes himself/herself to the litigious tactics of the public, irrespective of whether they are actual causative factors or not.1 The major reasons for this are, firstly ignorance about medical law and ethics by the young medicos, leading to the consequences of negligent behaviours/failure to discharge compulsory duties towards the patient and the state, amounting to either infamous conduct or negligence charges. Secondly, members of the general public are becoming increasingly aware of their rights due from a doctor, questioning the legality of issues.2 Hence, it is absolutely essential that every member of medical profession clearly knows what exactly are their compulsory duties and proper behaviour towards their patients. They should also know who are the authorities proposing these rules and what penalties one is likely to be punished with in the event of breach of them. Origin of Medical Ethics is as old as the origin of Medicine. To the earliest man, medicine was known in the form of magic, witchcraft, worship and various objects of nature. To protect themselves from their charlatan effect, ancient men framed set of regulations to control these medical men, this may be marked as the earliest code of ethics. About the medical ethics in India, details mentioned have been noticed in the first treatise on Indian medicine, i.e. Agnivesa Charaka Samhita: Charaka’s Oath, supposed to be composed in about 7th century BC. It is said that specific codes regarding the training, duties, privileges and social status of the physicians were mentioned in it.3,4 CHARAKA’S OATH According to this, the teacher instructed the disciples, in presence of sacred fire, Brahmans and Physicians thus: Thou shalt be free from envy, not cause other’s death, and pray for the welfare of all creatures. Day and night, thou shalt

Chapter 4: Ethics of Medical Practice

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Ethics of Medical Practice

be engaged in the relief of patients, thou shalt not desert a patient, not commit adultery, be modest in the attire and appearance, not be drunkard or sinful, nor associate with abettors of crimes. A person known to the patient shalt while entering a patient’s house, accompany you. The peculiar customs of the patient’s household shall not be made public. Arthashastra of Kautilya of 3rd-5th centuries BC is considered to be further improvised code of ethics. Here, physicians were required to have taken a written permission from the ruler (king) to practice medicine, their practice being regularised from time to time and they were punished for negligence.3 Sushruta, the Father of Indian Surgery was another famous authority in Indian system of medicine, which composed Sushruta Samhita (200-300 AD) and defined clearly the qualities, responsibilities and duties of physicians. They were so carefully written that they are in no way inferior to the modern concepts of medical law and ethics.4 However, the Medical Council of India (founded in 1933) formulates the modern code of medical law and ethics in India. It is framed and worded on the same line as in the Declaration of Geneva by the World Medical Association, which again is a restated modern version of the oldest code of medical ethics, the Hippocratic oath: held in high esteem by every medical professional.5 CODES OF MODERN MEDICAL ETHICS Modern code of medical ethics is basically developed from several ethical principles put forth by noble men and organisations in medical profession from the historical period of medical practice such as Hippocratic oath, Declaration of Geneva and International Code of Medical Ethics, etc.5,8 Although these are apparently three separate codes, they are framed well dependent on each other, more so with Hippocratic oath. Added to this are Declaration of Sydney, Declaration of Tokyo, etc. which are recent in origin.6,7,8 Hippocratic Oath Hippocratic oath is the oldest code of medical ethics, which is 25 centuries old now; its basic tenets remain as valid as ever. However, the historical attractiveness of archaic language and formulations, which became anachronistic, led to the restatement of the same in the Declaration of Geneva. New doctors at convocation ceremonies formerly pledged Hippocratic oath, though this is rare now. An English translation of this oath is given below: • I swear by Apollo the physician, and Aesculapius and Health, and All-heal, and all the Gods and Goddesses, that according to my ability and judgement:

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Part II: Medical Jurisprudence

• I will keep this oath and this stipulation—to reckon him who taught me this art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. • I will follow the system of regimen, which, according to my ability and judgement, I consider for the benefit of my patients, and abstain, from whatever is deleterious and mischievous. • I will give no deadly medicine to anyone if asked, or suggest any such counsel, and in like manner I will not give to a woman a pessary to produce abortion. • With purity and holiness, I will pass my life and practice my art. • I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. • Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and further, from the seduction of females or males, of freemen or slaves. • Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. • While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. But should I trespass and violate this oath, may the reverse be my lot. Declaration of Geneva Following the gross transgression of medical ethics during Second World War, the World Medical Association restated the Hippocratic oath in a modern style, and called it as Declaration of Geneva, as given below: • I solemnly pledge myself to concesrate my life to the service of humanity. • I will give to my teachers the respect and gratitude that is their due. • I will practice my profession with conscience and dignity. • The health of my patient will be my first consideration. • I will respect the secrets, which are confided in me. • I will maintain by all means, in my power, the honor and the noble traditions of the medical profession. • My colleagues will be my brothers. • I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient. • I will maintain the utmost respect for human life from the time of conception. • Even under threat, I will not use my medical knowledge contrary to the laws of humanity.

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Declaration of Sydney This was the first published to guide to determine the time of death of comatose donor in brain death. The patient is not dead until the life support has been withdrawn. This was first adopted by the 22nd World Medical Assembly, Sydney, Australia, August 1968, and amended by the 35th World Medical Assembly,

Venice, Italy, October 1983, and the WMA General Assembly, Pilanesberg, South Africa, October 2006. Following is the text of this declaration released on June 14, 2006.6 • Determination of death can be made on the basis of the irreversible cessation of all functions of the entire brain, including the brainstem, or the irreversible cessation of circulatory and respiratory functions. This determination will be based on clinical judgment according to accepted criteria supplemented, if necessary, by standard diagnostic procedures and made by a physician. • Even without intervention, cell, organ and tissue activity in the body may continue temporarily after a determination of death. Cessation of all life at the cellular level is not a necessary criterion for determination of death. • The use of deceased donor organs for transplantation has made it important for physicians to be able to determine when mechanically-supported patients have died. • After death has occurred, it may be possible to maintain circulation to the organs and tissues of the body mechanically. This may be done to preserve organs and tissues for transplantation. • Prior to postmortem transplantation, the determination that death has occurred shall be made by a physician who is in no way immediately involved in the transplantation procedure. • Following determination of death, all treatment and resuscitation attempts may be ceased and donor organs may be recovered, provided that prevailing requirements of consent and other relevant ethical and legal requirements have been fulfilled. Declaration of Tokyo This was first published in 1975. Declaration of Tokyo gives the guidelines for medical doctors concerning torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment. This was adopted by the 29th World Medical Assembly, Tokyo, Japan, in October 1975. It is the privilege of the medical doctor to practice medicine in the service of humanity, to preserve and restore bodily and mental health without distinction as to persons, to comfort and to ease the suffering of his or her patients. The utmost respect for human life is to be maintained even under threat, and no use made of any medical knowledge contrary to the laws of humanity. For the purpose of this declaration, torture is defined as the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason. Following is the text of this declaration released:7 • The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedure is suspected, accused or guilty, and whatever the victim’s belief or motives, and in all situations, including armed conflict and civil strife. • The doctor shall not provide any premises, instruments, substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such treatment. • The doctor shall not be present during any procedure during which torture or other forms of cruel, inhuman or degrading treatment are used or threatened.

Duties of Doctors to Each Other (Medical Etiquette) The terminology is used to indicate the conventional law of courtesy to be observed among the members of medical profession.8 It is the rules of conduct growing the relationship in the medical profession and includes the following: • A doctor ought to behave to his/her colleagues, as he/she would have them behave to him/her. • A doctor must not entice patients from his/her colleagues. • A doctor must observe the principles of “The Declaration of Geneva approved by the World Medical Association”.

INTERNATIONAL CODE OF MEDICAL ETHICS This was first adopted by the Third General Assembly of the World Medical Association at London in October 1949.8 International code of medical ethics is again solely based on Declaration of Geneva and framed as sets of duties of doctor in general, to the sick and to each other. The English text of this code is as follows:

CODES OF MEDICAL ETHICS IN INDIA The Medical Law and Ethical Codes for the medical professionals in India are prescribed by the Indian Medical Council, under the section 20-A of Indian Medical Council Act of 1956 and Amendment Act No: 24 of 1964.10,11 The text of the code is actually prescribed in two parts: The Declaration and the Code Proper.

Duties of Doctors in General • A doctor must always maintain the highest standards of professional conduct. • A doctor must practice his profession uninfluenced by motives of profit. • Following practices are deemed unethical: – Any self-advertisement except such as is expressly authorised by the national code of medical ethics. – Collaboration in any form of medical service in which the doctor does not have professional independence. – Receiving any money in connection with services rendered to a patient other than a proper professional fee, even with the knowledge of the patient. • Any act or advice, which could weaken physical or mental resistance of a human being, may be used only in his/her interest. • A doctor is advised to use great caution in divulging discoveries or new techniques on treatment. • A doctor should certify or testify only to that which he/she has personally verified.

The Declaration This is based on Declaration of Geneva. At the time of registration as registered medical practitioner each applicant shall be given a copy of the declaration by the Registrar of concerned State Medical Council and shall be made to read and agree to abide by the same. The actual text of declaration of the code is provided by the Medical Council of India, is medical ethics in India, may be presented as follows:

Duties of Doctors to the Sick • A doctor must always bear in mind the obligation of preserving human life. • A doctor owes to his or her patient complete loyalty and all the resources of his/her science. Whenever an examination or treatment is beyond his/her capacity, he/she should summon another doctor who has the necessary ability. • A doctor shall preserve absolute secrecy on all he/she knows about his/her patient because of the confidence entrusted in him. • A doctor must give emergency care as a humanitarian duty unless he/she is assured that others are willing and would be able to give such care.

Declaration of Helsinki This code of conduct for doctors emerged during 1964, introduced by the World Medical Association. It was revised in Tokyo in 1975, and governs medical research.9 This was intended purely to embark upon any experimental scheme of treatment or whenever clinical trials for a new drug were proposed on human beings as an experiment. Such experimentations upon human beings were more common during the Second World War, involving most of the war prisoners, as experimental subjects, for a new drug or other novel methods of treatment in medicine.

Chapter 4: Ethics of Medical Practice

• A doctor must have complete clinical independence in deciding upon the care of a person for whom he/she is medically responsible. The doctor’s fundamental role is to alleviate the distress of his or her fellow men, and no motive whether personal, collective or political shall prevail against this higher purpose. • Where a prisoner refuses nourishment and is considered by the doctor as capable of forming an unimpaired and rational judgement concerning the consequences of such voluntary refusal of nourishment, he/she shall not be fed artificially. The decision as to the capacity of the prisoner to form such a judgement should be confirmed by at least one other independent doctor. The consequences of the refusal of nourishment shall be explained by the doctor to the prisoner. • The World Medical Association will support, and should encourage the international community, the national medical associations and fellow doctors to support the doctor and his/her family in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment.

Declaration of Code of Medical Ethics in India • I solemnly pledge myself to consecrate my life to the service of humanity. • Even under threat, I will not use my medical knowledge contrary, to the laws of humanity. • I will maintain the utmost respect for human life from time of conception. • I will not permit consideration of religion, nationality, race, party politics or social standing to intervene between my duty and my patient. • I will practice my profession with conscience and dignities. • The health of my patient will be my first consideration. • I will respect the secrets, which are confided in me. • I will give to my teachers the respect and gratitude that is their due. • I will maintain by all means, in my power, the honour and noble traditions of the medical profession. • I will treat my colleagues with all respects and dignity. • I shall abide by the code of medical ethics as enunciated in the medical council regulations, 2002 (Professional Conduct Etiquette and Ethics) • I make these promises, solemnly truly and upon my honour. Place Signature Date Name Address 25

Part II: Medical Jurisprudence

The Code Proper Code of Medical Ethics Code proper and other laws prescribed by the Indian Medical Council is dealt with in detail under separate side headings below, namely: Indian Medical Council and State Medical Council, Registered Medical Practitioner, Professional Misconduct, Professional Secrecy, Consent, Medical negligence. INDIAN MEDICAL COUNCIL (IMC) The Indian Legislative Assembly, in the year 1933, passed an Act, The Indian Medical Council Act, 1933 (Act No: XXVII of 1933). With this the Indian Medical Council was created. This Act, however, now got amended by the Indian Medical Council Act, 1956, and the Indian Medical Council (Amendment) Act, 1964, which extend to the whole of India.1,10-12 The medical profession in India is thus brought under the control of Indian Medical Council, by maintaining a register, entering the names of all Medical Practitioners of the country in it, before being allowed to practice the art of medicine. It lays down actual code of conduct (ethical codes) for the medical profession in India based on Geneva Declaration, which each qualified Medical Practitioner has to agree to and abide by, at the time of getting his/her name registered in the register of the council (through State Medical Council). The formation of the office actual, the functions proper and medical law and ethical codes of the Indian Medical Council may be discussed in detail now.

Office of Indian Medical Council Indian Medical Council’s office is situated in the capital of the country – New Delhi and comprises of a set of members of the profession from each state and universities by election, as well as by nominations directly by the Government of India in consultation with State1,4,10-14 Governments (Fig. 4.1). Thus, it will have: • One member from each state (appointed by government). • One member from each university (elected). • One member from each State Medical Register, representing non-Indian degrees (Part-II, III schedule) (elected). • Seven members from each State Medical Register representing Indian degrees (Part-I, III schedule) (elected). • Eight members nominated directly by Central Government. The above body through election from among themselves forms an executive committee comprising of two officers: President and vice-president and 20 members. The Secretary who is a paid executive of the council is an ex-officio member. However, any number of subcommittees comprising of 7 to 10 members may be formed to carry out the functioning of the council from above group. Duration of the Office The tenure of the council is for a term of not more than 5 years or till new office is formed.

Fig. 4.1: Formation of Medical Council of India

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Functions of Indian Medical Council10-18

Maintenance of Medical Register An officer by name Registrar is appointed by the Council, who will maintain a register called Indian Medical Register. This contains the names of all medical persons who are enrolled on any of the State Medical Register and who possess a recognised medical qualification. A name once entered is erased normally on death of the doctor or as a disciplinary action. Names may also be erased temporarily and then reentered, depending on the time and condition of disciplinary actions taken. Maintenance of Medical Education Postgraduate education: It prescribes standards of postgraduate medical education for the universities and would also offer advice to universities so as to maintain uniformity all over the country. Undergraduate education: It maintains standards at undergraduate medical education by appointing inspectors who inspect the facilities and examinations held by universities/medical institutions is in India, the purpose being to recommend recognition of the qualification to Central Government.

Indications for Inspection MCI may arrange for an inspection of a medical college under following circumstances: • For every medical qualification when it is newly introduced. • For every five years routinely, to determine the standards, equipments, training, staff pattern and other facilities. If the inspection result is unsatisfactory, the inspectors concerned can make recommendation to the Medical Council of India for withdrawing recognition accorded earlier. Recognition of Foreign Medical Degrees Two important sections of Indian Medical Council Act 1956, govern this10 and they are: Section 12, empowers the council to recognize medical qualifications granted by institutions outside India and to enter in a scheme of reciprocity with Medical Councils of Foreign Countries in the matter of mutual recognition of medical qualifications between the two countries. Section 13(4) of the same Act, gives authorisation to the council to recognize foreign medical qualifications which are not included in the schedule (II), based on reciprocal recognition. Procedure: A person with such qualification should first send an application through Central Government. The full literature regarding the course of study, syllabi, duration of the course, etc. may also be required to be furnished. The council may consult directory of medical institutions published by WHO. Appeal against Disciplinary Action The Indian Medical Council can give advice to the Central Government (Health Ministry) regarding appeals preferred by a medical practitioner against the decisions taken by the State Medical Council on disciplinary matters.

Procedure of Appeal The medical practitioner, against whom the State Medical Council has taken disciplinary action, may appeal to the Central Government in writing stating the grounds of the appeal and be accompanied by all relevant documents including a receipt for paying the nominal fees (Rs. 20/-) to Central Government. The appeal should be filed within 30 days from the date of decision appealed against. The Final Decision The final decision of the Central Government, which is given after consulting Indian Medical Council, is final and binding on the State Government and the State Medical Council. Warning Notices Indian Medical Council may issue warning notice to every doctor at the time of getting enrolled as Registered Medical Practitioner. This comprises of information about certain unethical practices known as infamous conduct in a professional respect.10,15,16

Chapter 4: Ethics of Medical Practice

Codes of Medical Ethics Prescribed Though the Indian Medical Council prescribes the ethical codes, their enforcement rests with the State Medical Councils and various aspects of the same will be discussed under State Medical Council separately.

Explanation Warning notice hence implies that whenever a Registered Medical Practitioner commits professional misconduct, they are selfwarned about the offence and the consequences of disciplinary action by the State Medical Council. Thus, warning notice is not a written letter or notice or any document by State Medical Council or Indian Medical Council through post or a messenger to the offending Registered Medical Practitioner. The council usually appoints a secretary for its day-to-day work. The secretary is the executive officer of the council. He/ she shall maintain the Indian Medical Registrar and is to update it periodically by erasing the names of practitioners who have: • Died • Convicted by criminal court • Guilty of professional misconduct He shall also restore the names of those doctors whose period of temporary erasure expires. STATE MEDICAL COUNCIL (SMC) After the Indian Medical Council Act 1933, 1956 and the Amendment Act of 1964, several State Governments have created State Medical Councils bypassing the State Medical Acts, to keep a control over the medical profession at a State Level. The formation of the office actual and the functions proper of State Medical Council are discussed.5,8,10,13,15,16 Office of State Medical Council Each state medical council comprises of a set of members of the profession from the state by election, as well as by direct nomination by State Government. Thus, it will have: • Members from Registered Medical Practitioners at the State (elected). • Members directly nominated by the State Government. This body elects from among themselves president and vice-president. In addition a registrar is appointed to be in-charge of day-to-day administration. Duration of the Office The duration of the office is for a maximum period of 5 years or till new office is formed.

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Functions of State Medical Council

Maintenance of Medical Register The State Medical Council also maintains a State Medical Register. This Register will contain the name, address, qualifications and date of qualification of every person who is registered under this Act on paying a prescribed fee. On registration a number is allotted to each person with a certificate, enabling him/her to be considered as Registered Medical Practitioner.5,10,11 Display of this certificate in the place of his/her practice helps the lay public to distinguish a qualified doctor from the unqualified. It is the duty of the Registrar to inform Indian Medical Council, from time-to-time, about the additions and deletions from the State Medical Register regularly. Disciplinary Control Though the other functions mentioned above form the bulk of the Council’s workload, it is the disciplinary function (Fig. 4.2), which is most controversial and receives maximum attention from the medical profession, public and the press. The State Medical Council Acts empower the respective council to erase the name of any doctor from the Register, when convicted of any felony, misdemeanor, crime or offence, or judged after due enquiry by the council to have been guilty of infamous conduct in a professional respect (Professional Misconduct). This power of the councils is intended to protect the public and not to be a punitive measure against attending practitioners, though the deterrent value is admitted. As erasure or suspension is the most serious professional disaster, which can overtake the doctor, the disciplinary machinery of the Medical Councils should be fully understood by every practitioner.

Disciplinary Enquiry Disciplinary enquiry may arise usually from two sources. • Accusations of professional misconduct either from a member of the public or a professional colleague or a certain public officer. • A statutory notification from the court officials where a doctor is convicted for any criminal offence. Procedure On receipt of such a notification or accusation of professional misconduct, the Registrar of State Medical Council submits it to the President and on scrutinising the same one of the following is opted.6-10 • Rejection of the case: Obviously false, malicious or otherwise unfounded trivialities are rejected at this stage (acquittal if no prima facie case existing). • Submission to special committee: The cases, which cannot be rejected, shall be referred to a special committee of the President and a few other members, one of whom is a nonmedical man of good repute. The committee will examine the facts of the case and on giving an opportunity to the accused doctor to defend, refers the case to the disciplinary committee, who decides the punishment under disciplinary action. The disciplinary committee is the definitive body of the State Medical Council, which hears cases of serious nature or offences, which have been repeated after previous warnings by subcommittees. The committee has to decide the disciplinary actions enumerated below: – Acquittals: The case may be dismissed if no prima facie evidence against the accused. – Warning: If it is a case of first offense, doctor may be sent back merely with warning not to repeat the same. – Suspension: It is the eraser of the name of the doctor from the register for a specific period considering the gravity of offense, to be reinstalled at the end of the period of suspension. Penal Erasure (Professional Death Sentence) This means erasure of the name of the doctor from the register permanently when the offense is confirmed beyond doubt allowing not to practise the profession. When a practitioner’s name has been erased from the register, he/she may apply for restoration at various fixed intervals. He/she may also appeal to the Central Health Ministry against the decision of the State Medical Council. REGISTERED MEDICAL PRACTITIONER Definition A Registered Medical Practitioner is a qualified doctor who has been registered in State/Indian Medical Councils.

Fig. 4.2: Disciplinary functions of State Medical Council

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Procedure of Getting Registered After passing qualifying examinations (MBBS) one has to undergo a period of compulsory training of internship (House Surgeonship) for a period of minimum one year in an institution approved by the Indian Medical Council. On completion of this training he/she will have to fill in certain application forms and pay the nominal fee to the State Medical Council. The office which will then scrutinize the contents in the application and if approved, enters the name of the doctor in the register, and provides him a Registration Certificate and a code number by which he/she may be referred for all further communications.

Merits of Registration as Registered Medical Practitioner On getting registered a doctor has certain merits such as achieving some special rights and privileges. He/she also have to perform certain duties towards the patients and the state. Both of these are discussed below.5,7,10-17 Rights and Privileges of Registered Medical Practitioner • He/she is legally recognised as medical man and is entitled to possess/dispense, to prescribe medicines listed in dangerous drug act. • He/she can set up medical practice anywhere in India. • He/she is enabled to hold official and semi-official (government) appointments at public hospitals. • He/she is entitled to sign statutory medical certificates, such as for birth, death, mental illness, etc. • He/she is entitled to sue for recovery of his or her fees in court of law. However, gratuitous service may be rendered to a deserving poor patient, as well as to all other physicians and his/her dependent family members. • He/she is entitled to perform medicolegal autopsies. • He or she is entitled to give evidence at any inquest or in any court of law as an expert. • He/she is exempted from serving on a jury and at an inquest. • He/she can choose his/her patient. • He/she can add title, description, etc. to his or her name. Duties of Registered Medical Practitioner • To exercise a reasonable degree of skill and knowledge in treating a patient. • To attend and examine a patient as long as there is a need after commencing the treatment. However, he/she can terminate his/her services, when another physician attends his patient or the patient starts using remedies other than those prescribed by him/her. • To provide proper and suitable medicine to the patient either directly or by a prescription. • To give proper instructions to the patient or relative of the patient regarding the use of medicine, dosage schedule, diet, etc. and warn the dangers if not used properly. • To appoint a substitute doctor during temporary absence, with the consent of patient, especially in obstetrics and gynecology cases. • To warn the possibilities of cross-infecting the others, in case the patient is suffering from communicable disease. • To take proper care of children and adult patients, who are unable to take care of themselves. • To inform all the risks involved in treatment plan. However, under the Doctrine of therapeutic privileges doctor need not disclose everything.6-10 • To handle poisons carefully and give proper treatment to a poisoning case and also cooperate with law enforcement authorities in deciding whether the case is a suicide, homicide or accident.

• To inform health authorities of a communicable disease reported to you under the Doctrine of privileged communication forgoing the professional secrecy principles of ethical code.6-10 • To exercise all duties with regard to surgery, i.e. taking consent, operating under proper anesthesia, aseptic measures, pre- and postoperative care, etc. • To treat war prisoners, civilians of any country, etc. under the duties proposed in Geneva Convention. • To refer a patient to specialist/consultant as and when needed on taking prior consent. • To take an X-ray of injured part (unless trivial) for ruling out fractures. • To maintain a perfect professional secrecy.

Chapter 4: Ethics of Medical Practice

Declaration At the time of registration, the Registrar of State Medical Council will provide a declaration form, which contains all the medical law and ethical codes. The doctors has to sign this and get attested by Registrar/a Registered Medical Practitioner and return it to the Registrar, will have to be abide by the same, breach of which will lead him to the charges of professional misconduct, which leads to the punishment of either warning or penal erasure.

PROFESSIONAL MISCONDUCT (Synonyms: Infamous Conduct) Definition Professional misconduct can be defined as something done by a doctor in profession, which is considered as disgraceful and dishonourable by his or her professional brethren of good repute and competence, after the enquiry by the State Medical Council. Punishments Under disciplinary control the State/Indian Medical Council decides this and depending on the type of misconduct punishment can be: • Warning • Suspension • Penal erasure (professional death sentence). Examples The potential reasons for penal erasure or suspension from the register are limitless. However, a few examples are enumerated below. Each of these is also called as ingredients of professional misconduct and listed under 6 A’s.8,11 • Association with unqualified persons • Advertising • Adultery • Abortion (illegal) • Addiction • Alcohol. Apart from these, the councils can also consider any other form of alleged infamous conduct, which is not in the above list for deciding the punishment.

Association with Unqualified Persons Following may be considered as suitable examples: • Employing unqualified or unregistered assistants. • Assisting an unqualified person for some purpose. – Ghost surgery: Here a qualified surgeon performs a surgery on a patient on behalf of an unqualified, who enters the operation theater after the patient is anesthetised and leaves prior to returning to consciousness.8 – Covering of unqualified persons: Here a qualified doctor covers unqualified persons as to enable them to practice midwifery by issuing a certificate to them, which enables them to conduct such practice. However, this is not applicable where in proper training is offered to bonafide medical students/dispensers/surgery attendants and skilled technical assistants, under the supervision of qualified and registered medical practitioners. Conversely, the said registered medical practitioner is held responsible for all

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mistakes committed by these trainees/students (vicarious liability).

Advertising Includes three modes, namely direct advertisement, indirect advertisement and canvassing: Direct Advertising • An unusually big name plate or signboard announcing the structure of fees collected from the patient, any concession, etc. (Fig. 4.3). • Inserting name in a telephone directory in a special place, in bold type prints, etc. • A prescription paper containing appointments held. • Notification in the lay press (Fig. 4.4) of his/her addresses or telephone number/consulting hours unless he/she has: – Started practice afresh – Change of practicing place – Resumed practice after a temporary absence from duty, such as on returning from a short vacation or visit abroad – Changed the type of his practice. Note: In each of these instances the advertisement should not appear more than twice, in two newspapers. Indirect Advertisement • Contributing articles to lay press (except on public health and allied matters). • Appearance, frequently in broadcasting media such as radios, television, etc. which have the effect of advertising. • Allowing the use of his/her name on price list of publicity materials, handbills, etc. Canvassing Canvassing includes use of touts or agents for procuring patients (Fig. 4.5). Adultery A medical man should maintain the highest professional standard and should not abuse his/her position to seduce a female patient (Fig. 4.6) or some other member of patient’s family. Abortion Abortion includes procuring, assisting or attempting to procure a criminal abortion.

Fig. 4.3: Illustration of a doctor’s name plate/signboard (Unusually large measuring 20’ × 5’) with consultancy rates and cost of various tests and medicine given etc displayed in the heart of the city in a prominent area. Note: It shows no address. Another signboard hanging from the roof at the entrance of the clinic

Addiction Supplying or selling addiction forming drugs to a person for other than medical grounds (Fig. 4.7). Alcohol Attending patients while under the effect of alcohol (Fig. 4.8).

Fig. 4.4: Notification in the lay press (A model)

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Chapter 4: Ethics of Medical Practice

Fig. 4.5: Using touts in procuring patients

Fig. 4.7: Supplying/selling drugs of addiction

Fig. 4.6: Doctor seducing a female patient

Fig. 4.8: Attending patients while on alcohol

Other Examples The Council can also consider any other form of alleged professional misconduct, which is not in the above list for deciding the punishment. Enumerated below are some more examples. • Avoiding consultations: In situations such as a case of poisoning, when a diagnosis is doubtful, when a case had taken a serious turn, when an operation is inevitable and a case is especially one of criminal assault. • In mutilating surgery case attending a patient who is under the care of another practitioner. • Issuing false certificates (Fig. 4.9) in respect of birth, death and cause of death, illness, injury, vaccination, mental illness, etc. • When the doctor is arrested/convicted by criminal court of law for offenses involving moral turpitude. • Contravening the provisions of the drug Act. • Selling scheduled poisons to people other than his/her own patients. • Running an open shop for sale of medicines, dispensing prescriptions of other doctors, or for sale of medical/surgical appliances.

Fig. 4.9: Issuing a false certificate

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• Writing prescriptions in a secret formula known to some pharmacy or chemist only. • Commercialisation of a secret remedy. • Refusing to give professional service on religious grounds. • Gross and prolonged neglect of duties. • Not attending a patient who is already under treatment. • Receiving/giving commission or other benefits to professional colleagues/a manufacturer/trader/chemist, etc. Giving of a commission by one doctor to another for referring, recommending, or procuring any patients for medical, surgical or other treatment is known as Dichotomy or Fee Splitting or Sharing (Fig. 4.10). • Lack of concern to respond in emergencies such as traffic accident, railway or air crash, etc. • Talking disparagingly about the colleagues (Fig. 4.11) or doing anything that amounts to unfair competition. PROFESSIONAL SECRECY

Fig. 4.10: Dichotomy/fees splitting/sharing

Definition Professional secrets are the ones, which a doctor comes to know about his/her patient in his professional capacity as a physician/ doctor.7-10,13,15-17 Explanation Part of the hippocratic oath affirms: ‘Whatever in connection with my professional practice or not in connection with it, I see or hear in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret’. Even if the medical graduate does not totally affirm this oath at qualification, he/she accepts it in its spirit and intention as his ideal standard of professional behaviour. Thus, the doctor should not divulge anything, which he/she has learnt in confidence from his/her patients/found on examining/noticed in the ordinary primacies of domestic life. This is not only a moral obligation but also a legal one, and practitioner is liable to damages if this is neglected.

Case Example The classic case example is case of Kitson vs. Playfair: Dr Playfair, a well-known Gynecologist, examined Mrs. Kitson, while her husband was abroad. Mrs Kitson was receiving an allowance of £500 per year from her husband’s brother. Dr Playfair regarded the pregnancy as illegitimate and communicated the circumstances to the brother-in-law, which led to his stopping payment of her allowance. Mrs Kitson brought an action for slander against Dr Playfair and the court found Dr Playfair as guilty for revealing the professional secrets and made him pay the damages of £12,000 to Mrs Kitson. Medicolegal Significance Thus, every practitioner should be very cautious to reveal statements confided in him by his/her patients outside the professional milieu. However, professional secrets may be disclosed and in fact it may become the duty of a doctor to divulge the same at times. Divulging a patient’s secrets on these occasions is called privileged communication. The doctor is said to get immunity for the communication on occasions described below: • Consent of patient to the disclosure of relevant information: Where disclosure is to be anything but informal, such as to relatives, it is wise to obtain written consent, or at least, witnessing oral consent. 32

Fig. 4.11: Talking disparagingly of a colleague

• Disclosure on the order of a court of law: When a Judge, Magistrate or Coroner orders a doctor to divulge the information about a patient that he/she has obtained out of his or her professional relationship, the doctor has to provide the details. However, he/she may continue to refuse at risk of fine or imprisonment for the contempt of court. Where a doctor honestly believes that disclosure would be a breach of confidence, he/she may request that he give the information in writing so that it is not made public. If these requests are not met, he/she has no other choice but to divulge or risk imprisonment.5-10 All matters voiced in court are absolutely privileged, and carry no risk of subsequent action for defamation of breach of confidence. • Divulging in the interests of the community: The most difficult situation of all for the doctor is where his/her ethical inclination towards silence battles with his/her conscience concerning the welfare of the community. Such instances arise when a patient holds some position in society and that, his/her illness may prove a public hazard6-10,21 as in following: – A hotel waiter diagnosed as typhoid carrier. – A barmaid diagnosed to be an open case of tuberculosis. – A bus driver who has pronounced hypertension or brittle diabetes.

•

•

•

•

CONSENT IN MEDICAL PRACTICE Every person has the right to have his body integrity protected against invasion by others and only rarely this can be compared (e.g. during arrest). Consent is the ethical precept that allows the patient to make invasion lawful–whether that invasion is into their body or their confidential information.2 Every human being of adult years and sound mind has a right to determine what shall be done with his own body, and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable for damages.13-22 Definition Consent is defined as voluntary agreement, compliance, or permission.

Chapter 4: Ethics of Medical Practice

•

– A railway engine driver who is colourblind or epileptic. – A person suffering from venereal diseases who is working as an attendant for a public swimming-pool/bath. – An individual suffering from fatal disease of AIDS (HIVpositive cases). The doctor here has a legal as well as ethical responsibility to warn the partners of AIDS patients. Since AIDS is invariably fatal, the physician-patient relationship confidentiality becomes secondary, when it involves potential harm to another individual. Disclosure of criminal matters on the order of a court of law: It may happen that a practitioner is called to treat a patient who is found to be a criminal, guilty of an offense of serious nature against law, in the due course of his/her examination. Mentioned below are few examples with instructions as how the doctor should act.5-8 – If the patient is a murderer, doctor can treat his or her ailment but should inform proper authorities. – When the patient happens to be a victim of rape, call/inform police immediately. – Dying declaration: Doctor should arrange for dying declaration/deposition if the patient is about to die, by calling police/magistrate accordingly. Always try to obtain a second opinion about the case whenever possible. Disclosure about the servant to the master: When a master has sent a servant for medical examination, master would naturally like to know the results of examination, as to assess the servant about his/her capacity to work. Here, if the communication is supposed to be privileged it is made only to the employer, and only in cases where the employer has an interest in knowing. However, such reports should be confined to those matters only, which have an immediate bearing on the question at issue, viz. fitness for service/ necessity for leave/extent of disability, etc. In all such cases, it is better to obtain the consent of the servant to divulge the information to the master or refuse to examine him or her.8-11 Disclosure about the life insurance medical examiners reports: A doctor here can inform anything found on examination, as for example, high blood pressure, and the proposer cannot take any action against this, as such reports are privileged. It is taken for granted that the condition of his/her health will have to be reported, if he/she wants to be insured. However, exceptionally the case now examined may be an old patient of yours for whom you have treated for certain ailments, which he or she is now completely cured of. There shall be no sign of the disease now on examination. Under such circumstances, the doctor need not report the disease from previous knowledge, as it would amount to breach of professional secrecy. In such cases, it is better to refuse examination on account of previous knowledge.7,8 Professional secrets and enquiries: Queries may be addressed to a doctor on a person examined earlier, by insurance company/solicitor/any one else even the nearest relative of the patient. Except when the patient is a child below age of 12 years age, the doctor, without the prior consent of the patient to do so, answers no information. Divulging information on cause of death: The doctor, without taking prior consent of the nearest surviving relative should not answer any enquiries about the cause of death of a deceased person.

Consent and its Validity It becomes legally valid, when it is given only after understanding: • What it is given for? • The risks involved in consequence. • Fulfills the rules of consent. Consent from a patient to a doctor is a must for examining or treating especially when the law demands it for any reason. Types of Consent Consent in routine medical practice is basically of two types: Implied Consent and Expressed Consent.

Implied Consent It is the most common type of consent observed in routine medical practice. Here the consent is presumed to have been given when the patient enters doctor’s consulting room, summons the doctor to his/her house or holds his or her arm for an injection (Fig. 4.12). Reasons since the patient knows that the procedure of diagnosis/treatment, etc. is simple and straightforward, with little/ negligible/no risk, and the conduct of patient implies the willingness to undergo the treatment. Expressed Consent Anything other than the implied consent described above is expressed consent. This may be of two types: oral and written consents.

Fig. 4.12: Implied consent for injection

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Oral Consent For majority of relatively minor examinations or therapeutic procedures, oral expressed consent is employed, but this consent should be obtained in the presence of a disinterested third party (Fig. 4.13). Usually presences of a receptionist or a ward sister/ nurse, etc. any one of the following suffice the purpose. However, a person closely related/associated with the patient is not ideal for the purpose. Oral consent, when properly witnessed, is of equal validity to written consent, but the latter has the advantage of easy proof in permanent form or document which avoids further disputes in any subsequent litigation.

Written Consent It is obtained for all major diagnostic procedures and for surgical operations (Fig. 4.14). However, following may be noted. • Consent should refer to only one specific procedure. As far as possible consent for more than one procedure i.e. blanket consent should be avoided in routine practice. • Consent should be obtained on a special form provided for the purpose by the hospital/institution. • A third party with a proper signature should witness consent. • The doctor should explain the nature of therapeutic or surgical procedures in advance. However, an exception to this is doctrine of therapeutic privilege (refer below). Even with consenting patients, where a female patient is to be examined by a male doctor, ensure the presence of a female nurse /receptionist/female relative of the patient especially when the following has to be done. • Intimate examination of the patient. • When anesthesia is to be given, as for minor surgical procedures. RELEVANCE OF CONSENT IN MEDICAL PRACTICE As already mentioned every person has right to decide what to do with his/her body.1,2,5,7-10 A doctor may be charged with the offence of battery/assault (Section 351, IPC) or even medical negligence if he/she has failed in obtaining consent on giving all instructions about the procedure of treatment, prior to its commencement. However, one may consider following three situations to understand the relevance of consent in practice of medicine. • Consent in relation to certain diagnostic and therapeutic purposes. • Consent and certain deviations and exceptions. • Consent in relation to medicolegal purposes. Consent in Relation to Certain Diagnostic and Therapeutic Purposes This is better understood by discussing under the parameters of rules of consent, Precautions during consent, and types of consent.

Rules of Consent Legal validity of consent obtained is based on certain rules and formalities maintained in obtaining it. Consent should be always free, voluntary, informed, clear and direct. Apart from this, the person giving consent should be above the age of 12 years. He/she must be mentally sound and should not be under any fear/threat/under any false conception/intoxicated (Section: 90, IPC). 34

Fig. 4.13: Expressed consent (Oral) is must in all minor procedure with disinterested 3rd party

Fig. 4.14: Expressed consent (Written) is must in all major diagnostic/ surgical procedures

Doctrine of Informed Consent (Synonym: Rule of Full Disclosure, Written Informed Consent, Informed Consent) It refers to written consent given by the patient after being informed of nature of illness, nature of operation or procedure to be done, its alternatives, its consequences and complications. This is essential in medical practice, when diagnosing or treating is beyond the routine methods, wherein risks are involved. Thus, the doctor should explain all relevant details to the patient. This is called rule of full disclosure. However, the doctrine of therapeutic privileges and emergency doctrine are exceptions for this rule (refer below). Precautions During Consent These include formalities on how a doctor should act in obtaining consent: • Explain the object of it. • Inform the patient that he/she has the right to refuse. • Explain the complete procedure of treatment.

Doctrine of Therapeutic Privilege At times it may not be possible to explain everything to the patient. Accordingly under such circumstances doctor can reveal the details to any one of the close relatives of the patient. This is called doctrine of therapeutic privilege. Case Example A patient who is to undergo the surgery of mitral valvotomy, if scared of a surgery on heart, he/she may not be told about the details of it, but any one of his/her close should relatives should be made aware of the entire procedure, its probable consequences/complications, etc. and the surgery should be performed telling him/her that it is a minor surgery (Fig. 4.15). Doctrine of Emergency According to this, a doctor can provide the treatment without taking prior consent from a patient who is gravely sick, critically ill, unconscious or not able to understand the suggestions or when mentally ill (Section 92, IPC). However, in such situation law presumes that consent is deemed to be given and protects the doctor’s interest giving him/ her immunity from proceedings against him/her for damages or negligence or assault (Section, 92, IPC). Section 92, IPC Nothing is an offense by reasons of any harm which it may cause to a person for whose benefit it has been done in good faith, even without that person’s consent, if circumstances are such that it is impossible for that person to sign consent, or if the person is incapable of giving consent and has no guardian or other person in lawful charge of him from whom it is possible to obtain consent in time for thing to be done with benefit. Case Example A victim of road traffic accident who is unconscious and with evidence of intracranial trauma clinically, requiring necessary

Fig. 4.15: Therapeutic privilege in mitral valvotomy surgery of the heart

surgery to save life. Doctor need not wait to take the consent and can proceed with surgery.

Situations Where Consent May not be Obtained Enumerated below are certain conditions wherein consent is not required.13,16 • Medical emergencies: Here the well-being of the patient is paramount and medical rather than legal consideration come first. • Notifiable diseases: In case of AIDS/HIV positive patients, the position in India is not yet clear. However, Supreme Court has held that hospital/ doctor would be under duty to inform about it to his/her ‘would be spouse’ of the danger of getting infected.25 Rather for not doing this would render doctor/ hospital punishable with participiens criminis under section 69 and 270 of IPC.21 In England, the Public Health (Infectious Diseases) Regulations, 1998 extends the provisions of modifiable diseases to AIDS but not to the person who is HIV positive. • Immigrants • Members of Armed Forces • Handlers of Food and Dairymen • New admission to prison • Incase of person where a court may order for psychiatric examination or treatment • Under Section 53 (1) of Code of Criminal Procedure, a person can be examined at request of police, by use of force. Section 53(2) lays down that whenever a female is to be examined, it shall be made only by or under the supervision of a female doctor.20

Chapter 4: Ethics of Medical Practice

Consent and Certain Deviations and Exceptions Rules of consent are though rigid in their legal implications, certain deviations are usually allowed and they are: • Doctrine of therapeutic privileges • Doctrine of emergency • Doctrine of locoparentis.

Doctrine of Locoparentis In emergency situations involving children, when their parents/ guardian are not available, according to this doctrine, consent can be obtained from the person accompanying. Case Example 1 A school teacher can give consent for treating a child acutely ill while on a picnic far away from hometown. Even if parents refuse consent, no blame will be attached to surgeon for a surgery done to save the life of the child. Case Example 2 If a student inmate in a hostel suddenly turns sick and unconscious, the warden in-charge of the hostel can take him/ her to a nearby doctor, who can give immediate treatment without waiting for the consent of the patient or his/her parents or relatives. The reason, which renders doctor to forgo the consent formality here, is, that, it is a case of emergency and unless the treatment is given immediately, life of the patient is in danger. This evolves the basis for concept of Emergency Doctrine (see Locoparentis). Consent and Age Rules regarding the age and eligibility to give consent in medical practice have following mandates.2,5-9 • Minimum age for giving valid consent for physical/medical examination is 12 years (Section 89, IPC). Accordingly, for medical examination of a child below the age of 12 years, the consent is to be obtained from the parent/ guardian of the child. However, it must be realised that doctrine of ‘informed consent’ has only limited to ‘direct’ application in paediatric practice. Only patients who have appropriate decisional capacity and legal empowerment can give their

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‘informed consent’ to medical care. In all other situations, parents or other surrogates provide “informed permission” for diagnosis and treatment of children with the ‘assent’ of the child whenever appropriate.12,14 Some relevant examples for this are: – Venepuncture for diagnostic study in a nine-year-old child. – An orthopaedic device to manage scoliosis in an elevenyear-old child. • A person who is above 18 years age can give valid consent to suffer any harm which may result from an act in good faith and which is not intended or known to cause grievous hurt or death (Section: 88, IPC). Thus, minimum age for giving valid consent to suffer any harm, which may result from an act in good faith, is 18 years. • In consequence a surgeon operating on victim of an accident is doing it for the benefit of the patient and he cannot be held responsible if the surgery ends fatally, as the doctor is acting in good faith. Consent in Relation to Medicolegal Purposes • In medicolegal cases where the law requests an examination, consent must be obtained whether it is victim or accused/ assailant to be examined. Without consent examination amounts to assault.21 Examination findings when used in process of investigation can damages the party examined. If later on the party is proved innocent, damages sustained cannot be undone. This is why the right to deny consent for examination is generally given to the party. Here the consent is of informed type and must tell the person to be examined that the examination findings may go against him/ her and can be used as an evidence in court. Explained below are certain medicolegal matters having relevance to consent in this regard.8,13-18,21 Marriage and conjugal obligations: Regarding consent in relation to these matters, such as sterilisation, artificial insemination, etc. consent of both the partners must be obtained. • Pregnancy (for examining to confirm it) and delivery: Consent (oral/written) must be obtained in advance from concerned woman. If this is not possible consent must be obtained from her husband or relative who is accompanying her. During examination of case/delivery, it is better to keep an uninterested third person as witness, preferably a nurse, receptionist or a female relative of the patient. • Medical termination of pregnancy (MTP ACT: 1971): Here the consent of the pregnant woman alone is enough for MTP. However, she should be above the age of 18 years. • Sexual intercourse: In India sexual intercourse with a consenting woman amounts to the legal offence of rape if she is below the age of 16 years and this is called as statutory rape. • Examination of rape victim: In the examination of a victim of alleged rape to confirm the allegation, the doctor should obtain prior consent observing all formalities. The consent must necessarily be after telling her that the findings of clinical examination shall be revealed in a court of law. Consent must be obtained from her relatives if the victim is a child or minor. • Examining any medicolegal case: In every medicolegal case, whether the patient is a victim or an assailant, consent must be obtained.

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• Consent and negligence charges: In medical negligence charges against a doctor, consent is not a valid defense. • Consent in drunkenness and intoxicated cases: Consent obtained from a person who is drunk/under the influence of alcohol is invalid. However, in such events, examination of the case may be done and findings may be revealed only after obtaining the consent at a later period when the person becomes sober. • Consent in examining criminal cases: Here no consent is necessary, provided the requisition is from a police officer who is not below the rank of Sub-Inspector of Police, and the examination is done in the presence of a disinterested witness (Section: 53, CrPC). However, a doctor as a routine, formally may obtain consent, and according to this section if the criminal is not willing to get examined, examination may be done with mild degree of force. When the criminal is a female, examination should be done only by or under the supervision of a lady medical officer. • Consent in unconscious: victims/assailants/any patient: Examination findings can be divulged to police only after the patient regains consciousness and gives consent for disclosure. CONSENT IN RELATION TO AUTOPSY AND ORGAN TRANSPLANTATION Consent in Relation to Autopsy Examination It is improper and illegal to perform autopsy without consent or authorisation. Consent differs with type of autopsy to be performed: • Consent is not required if it is a medicolegal autopsy. Here autopsy is done only with an authorisation. • Consent is a must from spouse or relatives for clinical or pathological autopsy. Failure to get consent here is a ground for charges of mutilation of deceased and emotional hurt by legal heirs. It could be ground for punitive damage (US Law). Consent in Relation to Remove and Retain Parts of the Body Specific consent must be obtained for this purpose. However, no civil action has so far been reported for the removal of tissues from the body at autopsy even without specific consent.8,9,11,12 Perhaps it may be justifiable to remove certain tissues for demonstration, even without consent during bonafide autopsies, done without visible mutilation of the body. Consent in Relation to Organ Transplantation In living: A person can donate voluntarily his/her organs, tissues, etc. to another person for therapeutic purposes. However, in India the consent given for such purposes becomes legally valid only if the donor is above the age of 18 years1,7-9,13,17,22 (in United Kingdom it is 16 years).22,23 Note: This is called as informed witnessed consent under Human Organ Transplantation Act, 3.22 It states that a living person should give his/her consent in writing to donate kidney, for the transplantation purposes, in presence of two or more witnesses, at least one of them should be a near relative of the person consenting.22 In dead: Consent should be given earlier by the person in writing in the form of a Written Will when he was alive. However, this consent or will made by the deceased when he/she was

MEDICAL NEGLIGENCE (Synonyms: Professional Negligence, Malpractice, Malpraxis) Medical negligence covers those defects in profession by a doctor where the standard medical care given to a patient is considered to be inadequate. It is also true that not all cases with negligent allegations are guilty of careless or incompetent actions in reality. However, every patient will have legal right to expect a satisfactory standard of medical care from a doctor, even though this can never mean that the doctor can guarantee a satisfactory outcome to the treatment. An effort is made to understand the concept of medical negligence. Definition Medical negligence is defined as want of reasonable degree of care and skill or willful negligence on the part of medical practitioner in treating a patient leading to injury or suffering or death.2,5-9 Explanation Negligence, medical or otherwise is a civil wrong known as tort, means failing to do something which one is supposed to do (Act of omission), or doing something which one is not supposed to do (Act of Commission). The law assumes that a medical man will always use reasonable degree of skill, care and prudence in the treatment of his/her patient. Figure 4.16, illustrates certain circumstances in medical profession resulting in negligence/malpractice. Extent The extent of care and skill a doctor is required to possess in medical practice is highlighted below: 1. A doctor is only expected to possess such skill and knowledge as possessed by any ordinary competent man practicing at given time. 2. He/She need not possess the highest skill and knowledge, i.e. he/she should follow the standard procedures and established methods of diagnosis and treatment. 3. However, following are exceptions: • A specialist is expected to exercise greater skill than a general practitioner. • An urban doctor with access to modern gadgets and facilities and up-to-date knowledge in medicine is expected to show better skill than a rural doctor. If the physician did not possess or exercise the reasonable skill and care expected of him or her, he or she fails in his legal duty causing damage. Doctrine of Res Ipsa Loquitor Res Ipsa Loquitor is a Latin terminology, literally means the thing speaks for itself.

Explanation The doctrine of Res Ipsa Loquitor applied in situations where the injury could not have happened, but for the negligence of the doctor.

Usually, in cases where negligence is alleged, the plaintiff is expected to prove that the defendant was negligent. But, when this doctrine is applied, the doctor will have to prove that what has happened is not due to his/her negligence. If the element of due care of the patient as exercised could be proved, the injury or complication developed can be presumed to be a consequence of error of judgement and not of negligence.

Examples Given below are certain examples (Fig. 4.16): • Foreign bodies left inside body cavities after operation. • Slipping of instruments during surgery resulting in injuries. • Injury of the body outside the field of operation. • Operation on wrong organ/wrong side/wrong patient. • Too tight plaster cast resulting in gangrene of foot/toes. • Giving medicines in overdose. • Giving injections in wrong site/route. • Failure to inject anti-tetanus serum (ATS) in case of injury. • Burns from careless use of X-ray/hot water bottles, etc. • Breaking needle while injecting, but not informing about it to the patient. • Mismatched blood transfusion.

Chapter 4: Ethics of Medical Practice

alive becomes null and void after his/her death and to remove organs from the dead body, consent must be obtained from legal possessors of the dead body. No law of the land can procure organs from the dead body if the legal possessor of the deceased refuses to give his/her consent to donate the organs or tissues.8,9,16,22

Classification Negligence or malpractice is actionable and a case may be brought against a medical practitioner in a civil or criminal court. Hence, it can be classified into two types.

Civil Malpractice (Civil Negligence) Civil malpractice is usually is of bifid nature: Either a patient bringing charges of negligence or malpractice allegation against a doctor for compensation towards the physical damages suffered by him/her, or a doctor bringing charges against a patient who fails to pay his/her dues on the grounds of charges of malpractice on the doctor, during the course of treatment. Note: The damage, in the sense of harm is quite different from damages, which is financial compensation awarded to a successful litigant. Enumerated below are few examples with suitable diagrammatic illustrations (Figs 4.17 to 4.22) allowing easy understanding of the concepts. The liability of doctor does not get mitigated even when either he/she treated the patient free of charges or in a charitable hospital. The doctor will not be liable for Error of judgement or Error of diagnosis. Examples • Failure to exercise proper care. • Failure to do essential diagnostic tests (Fig. 4.17). • Promising 100 per cent cure (Fig. 4.18). • Failure to give proper pre- and postoperative care (Fig. 4.19). • Mishaps while giving injection. • Giving injection in wrong site or by wrong route. • Failure to count swabs or packs properly at the end of surgery and leaving one inside and closing (Fig. 4.20). • Do not leave a patient unattended during labor (Fig. 4.21). • Do not perform additional surgery unless in emergency (Fig. 4.22). Criminal Malpractice Usually, patient’s party or patient brings the allegation of criminal malpractice against a doctor. Here the gross negligence of the doctor totally unconcerned with the life and safety of the patient is to be established against the doctor. Prosecutions for criminal malpractice are rare. 37

Part II: Medical Jurisprudence Fig. 4.16: Certain circumstances/examples in medical profession resulting in negligence/malpractice

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Chapter 4: Ethics of Medical Practice

Fig. 4.17: Failure to do/postponement of essential diagnostic tests

Fig. 4.20: Failure to count swabs, instruments, sponges, etc. at the end of surgery

Fig. 4.18: Failure to give proper preand postoperative care

Fig. 4.21: Do not leave the patient unattended during labour

Fig. 4.19: Promising 100 per cent cure

Fig. 4.22: Do not perform additional surgery unless in emergency

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Part II: Medical Jurisprudence

Examples • Cases of gross negligence such as removing healthy eye instead of diseased eye, amputating healthy limb instead of unhealthy one, etc. • Failure to reveal information to police, in all medicolegal cases. • Treating under contagious diseases. Punishments: Case can be tried by both civil and criminal courts and punished by imprisonment or fine as per law. Burden of Proof and Essential Ingredients of Medical Negligence The burden of proof of negligence or malpractice of the doctor lies on the plaintiff, i.e. the complainant. The essential ingredients for the proof of medical negligence are: • Duty • Dereliction/breach of duty • Direct causation • Damage. These four ingredients can be better remembered as 4D’s of malpractice.

Duty Here the party has to prove that there was an existence of a duty of care by the doctor. In other words it must be proved that at the time of causation of the injury, the patient physician relationship already existed and the doctor was thus duty-bound to care for the patient. It is immaterial whether the patient was being treated free of charges or not. Dereliction/Breach of Duty Dereliction or breach of duty comprises of the element of failure on the part of the doctor to maintain proper care and skill. Injury resulting from diagnostic or therapeutic procedures performed under the effect of alcohol or other intoxicants will be interpreted as lack of care. Similarly, injury resulting from a surgical procedure that is beyond the skill and experience of the doctor will amount to lack of skill. Direct Causation The party must prove that failure to exercise a duty of care acted as the proximate cause and led to the injury (damage). In other words, it must be proved that breach of duty was directly responsible for damage occurred. Damage Here the party must prove that the damage has actually been caused as a direct consequence of breach of duty. The damage resulted should be such that it permits objective assessment. Conditions such as shock, anxiety, and tension, which do not permit objective assessment, are not likely to be accepted by courts as damage (Refer Res Ipsa Loquitor). Other Criteria These include plethora of criteria, and are discussed individually: 1. Foreseeability of injury: See malpractice. If the injury could have been foreseen or predicted by a reasonably competent man, then the particular doctor is held guilty of negligence. 2. Intervention by third person: If there is an intervention by a third person (i.e. second doctor) between the alleged act of negligence by first doctor and injury, it is difficult to decide the negligence charge on the first doctor who treated first. 3. Contributory negligence: See malpractice. At times though the doctor was negligent, if patient also refused to extend 40

his co-operation (by not following the instructions given by the doctor, or failing to give full details of the ailment suffering, etc.) during the course of treatment, charges of malpractice may be examined so as to apportion the damages between the negligent doctor and such contributing patient. 4. Medical maloccurrence (Synonym: Inevitable Accident, Act of God): On certain occasion, despite all proper care given by the doctor during treatment, the patient might suffer severe injuries or permanent deformities. This is known as medical maloccurrence/inevitable accident (Act of God). If the doctor can prove this before the court, it will be an absolute defense against malpractice. 5. Therapeutic misadventure: A misadventure is mischance or accident or disaster, in which an individual is injured or died due to some unintentional Act by a doctor/hospital. It is of three types: – Purely therapeutic (when treatment is being given). – Diagnostic (where diagnosis is the objective at the time). – Experimental (where patient has agreed to serve as subject in an experimental study). It is a known fact that almost every therapeutic drug and every therapeutic procedure can cause death. A doctor is not liable for injuries resulting from adverse reaction to a drug. However, ignorance of the possibility of a reaction, or condition of adverse reaction to the drug prescribed to a patient, amounts to negligence. Doctor must warn his/her patient about the possible side effects of a drug, such as drowsiness by antihistamines, nausea with metronidazole on consuming alcohol, etc. Given below are certain examples for therapeutic misadventures. – Hypersensitivity reaction or anaphylaxis, sometimes severe and fatal as with drugs like penicillin, aspirin, tetracycline, etc. – Radiological procedures for diagnostic purposes may prove fatal, such as barium enema—resulting in traumatic rupture of rectum, followed by chemical peritonitis. – Damage by radiations or radioisotopes. – Injury due to electrical equipment. – Death during operation. – Death during blood transfusion. – Prolonged therapeutic prescription of stilbesterol resulting in breast cancer. Prevention of therapeutic misadventures Following precautions may help in reduction or prevention of therapeutic measures: – Prior to prescribing a drug, learn about the drug on any of its adverse effects and also treat such cases. – Sensitivity tests should be done before injecting preparations, which are likely to produce anaphylaxis. – Doctor should warn about permanent side effects of a drug if any, while prescribing if continued to take without further consultation of a doctor. 6. Error of judgement and negligence: A doctor may not be held responsible or liable for the deleterious effects of an Act proved to have resulted from error of judgement. However, if the error of judgement was the direct result of Negligent Act such as failure to do the essentials, it would amount to malpractice. 7. Professional negligence and infamous conduct: Professional negligence or malpractice usually does not amount to infamous conduct or professional misconduct. Infamous

Case Examples • Failure to utilize diagnostic facilities: Here the hospital is held responsible for the negligence of doctor, who failed to diagnose fracture of cervical vertebra from which the patient died. • Case of surgeon’s liability: A woman suffered from abdominal burns when painted with iodised phenol instead of tincture iodine during preparation for abdominal surgery. The court held the view that the surgeon was not vicariously liable for the negligence of the nurse as surgery is considered as teamwork and surgeon has to rely on certain work done by others in the team. • Borrowed servant doctrine: This refers to vicarious liability in relation to patient admitted to a private hospital by a private practitioner, who is not a staff of the hospital. Here, the private practitioner will be held responsible for all the Negligent Acts by any of the hospital staff (Nurse, compounder, etc.) on the patient admitted by him. The hospital will not be held here liable, because all the instructions for the patient admitted is carried on by the hospital staff as told by the private practitioner. • Vicarious liability on negligent acts by interns/ trainee doctors: Here hospital or unit heads will be liable for all the negligent acts of interns who are appointed by the hospital on salary. However, this will not be so, if the negligence complained of comes under the preview of doctrine of common knowledge.

According to this the doctor may be charged for negligent act for failing in involving application of common sense in routine practice. Necessity of fluid therapy for a dehydrated patient suffering from severe gastroenteritis is a matter of common sense or common knowledge. If doctor fails to do needful here, he/she becomes negligent and to prove this plaintiff need not show that doctor did not show reasonable degree of scientific knowledge, care and skill, etc. as it is common knowledge that patient needs fluid therapy for which doctor did not take proper step. • Product liability: This means liability of producer, agent or seller of medicine, an instrument, or appliance, use of which has caused the damage or harm to the patient. Doctor will not be held liable for this. The burden to prove this lies on the plaintiff. • Corporate negligence: It is the failure of the persons who are responsible for providing the accommodation and other facilities necessary to carry out/follow the established standards of conduct in a hospital. It occurs when the hospital provides defective equipment or drugs, selects or retains incompetent employees or fails in some other manner to meet the accepted standards of care, which may result in injury to the patient to whom the hospital owes duty. Thus, a doctor may be charged for negligence in his/her part of duty or a nurse may be charged if she does not take care of the patient according to the directions of the doctor. • The hospital superintendent may also be charged if he/she does not take steps to make the necessary things available for the patient, in time. Superintendent will not only be responsible for posting qualified persons for specific post, but he/she will also be obliged to see that every employee performs his/her part of duty to patient properly. • Vicarious liability and group medical practice. Each practitioner will be held liable for the negligent acts of the other, when they practice together as partners. Procedure to initiate charges of negligence against a doctor The charge of criminal negligence against the doctor is lodged by the public prosecutor. The sufferer patient may lodge the charge of civil negligence. It may come up when doctor sues the patient for non-payment of his/her fees and patient argues that there is no question of paying the doctor’s fees, as the treatment of doctor did not benefit him/her, rather caused damage to him/her.

Chapter 4: Ethics of Medical Practice

conduct involves the abuse of professional status, which lacks in negligence. However, allegation of criminal negligence if proved is also considered as infamous conduct in professional respect. The differences between these two are highlighted in Table 4.1. 8. Vicarious liability (Synonym: Liability for Act of another, principle of respondent superior): It means an employer is held legally responsible for all. The negligent acts of his/her employees or agents appointed by him/her. It also means, let the superior be responsible. The question of vicarious liability will be raised when doctors, nurses and other staff employed by a hospital are found to be negligent in discharge of their professional duties. If those staff members are employed under a contract of service on salary, the hospital will be liable for their negligence, irrespective of whether they are necessary or permanent, fulltime or part-time, or resident or visiting. The hospital may not be held liable for the negligent acts of a superior if it has exercised due care in selecting them. However, this may not be always true.

INSTRUCTIONS ON PREVENTION OF CHARGES OF NEGLIGENCE Box 4.1 presents certain precautions recommended to a doctor in avoiding negligence charges. In addition to these it may be

Table 4.1: Differences between professional negligence and professional misconduct Professional negligence

Professional misconduct

1. It concerns duties of a medical man towards his patient 2. There should be dereliction of duty in treatment causing damage to patient 3. Charges against erring doctor is brought before the court of law 4. May be punished as per Indian Penal Code as in other criminal cases or may be liable to pay compensation as in other civil cases 5. Appeal cases are lodged before higher courts

1. It concerns violation of codes and ethics of medical practice 2. There need not be dereliction of duty and damage to patient 3. Charge is brought before the state medical council 4. Where applicable, name of the erring doctor gets erased from Medical Council Register/ served warning notice and reprimanded. 5. Appeals are made to the Central Government

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Part II: Medical Jurisprudence

Box 4.1: Precautions recommended to a doctor in avoiding negligence charges

• • • • • • • • • •

Never guarantee a cure. Keep professional knowledge updated. Apply due care and skill in treating a patient. Take written consent in all steps of treatment if involves risk. Take consent of both husband and wife in giving treatment that may result in sterility or impotency. Advise laboratory investigations to confirm clinical diagnosis. Record the patient’s conditions and treatment given regularly. Consult professional colleagues whenever necessary. Always check the instruments and equipment’s prior to its use. Always check for the intactness, instructions and date of expiry, etc. of an injection ampoule or vial prior to its use.

• • • • •

Perform sensitivity test/test dose for a drug known to cause anaphylactic reactions. Immunize the patient whenever necessary. Injury due to assault and poisoning should be specially dealt with. Do not venture a procedure beyond the skills/field of specialisation. Avoid experimental treatment with a patient. But if it is necessary, proceed with written consent.

• • • • •

Write prescriptions clearly, legibly and neatly with proper instructions to the patient. Give optimum postoperative care. Avoid advises or consultations on phone. A qualified and experienced doctor should administer anesthesia. Do all needful check-up and give proper premedications prior to administration of anesthesia.

• • • • • • • • • • • •

Do not leave the patient till he/she recovered from anesthetic effects. Recommend inquest in case of death from anesthesia on an operation table. Choose your assistant with due care. Do not stop giving treatment unless the patient desires or agrees to it. Do not leave an emergency case unattended. Do not criticize a professional colleague. Arrange a substitute doctor with prior information if going on leave during treatment. Always refer your patient to better doctor or hospital if necessary. Always examine a female patient in presence of another female. Strictly maintain provisions of medical termination of pregnancy (MTP) Act. Always issue medical certificates with due care. Do not make statement-admitting fault on your part.

relevant to remember and reproduce here the nine R’s of malpractice prevention17 (Box 4.2).

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DEFENSES OF A DOCTOR AGAINST CHARGES OF NEGLIGENCE When charged for negligence, a doctor may plead any one/ more of following arguments as his/her defense: • He/she had no duty to the patient. • He/she discharged his/her duties in par with existing standards of medical practice. • The damage caused could be due to other person who was concerned in providing the treatment. • The damage was the result of third party intervention without his/her knowledge. • The case is contributory negligence. • The damage suffering is an expected outcome of the disease the patient suffered from. • The case is of reasonable degree of error of judgement. • The case is therapeutic or diagnostic misadventure. • The case is medical maloccurrance. • The case is Res-judicata (complaint should not be entertained by the court as it has already been tried once in court of law).

• The damage is the result of taking unavoidable risk, which was taken in good faith in the interest of patient with consent. • Patient persistently insisted on specific line of treatment, in spite of doctors warning. • The time limit allowed by the law for lodging such a complaint is over (complaints of negligence should be lodged within two years, counting from the alleged date of causation of damage). Note: Free treatment of patient does not absolve a doctor from his/her responsibility towards his patient and does not give him/ her immunity against negligence. MEDICAL INDEMNITY INSURANCE After the advent of Consumer Protection Act, and the Supreme Court verdict that all medical services by doctors meddling with their patients on payment come under this Act.16,26 The doctors are thus held liable for their negligent acts in the course of treatment. This has threatened the medical profession with uncertain situations of who among the patients treated by a doctor can be the potential consumer of the doctor and charge him with negligence charges and demanding huge sum of money for damages suffered by him as compensation.

Rapport Rationale Record Remarks

Rx Res ipsa loquitur Respect Risks

Maintain healthy rapport and communication with:· The patient and his family.· Fellow physicians· Office staff and nurses and other hospital personnel. Physician must understand what he is doing with his patients and why. The diagnostic and therapeutic rationale should be adequately documented. This can help the court in understanding the physician’s thought process. Record should be carefully prepared, complete, accurate, liable germane, timely and generously informative. A good record speaks of good care. This refers to the gratuitous oral statements made to the patient and patient’s family as well as to other members of the treatment team. In certain situations a stern warning, a forceful advice, is essential in handling uncooperative patient. But, harshness, excessive criticism, etc. will harm the good patient rapport. A doctor has to be cautious in passing remarks against another doctor who has treated the patient. Doctor should always keep the patients ailments confidential. Never prescribe medicine unless indicated. Doctor should be aware of drug reaction, allergy, etc. for a drug. Means ‘the thing speaks for itself’. The doctrine is applied in the court of law to refer to situations even an untrained layman will understand the malpractice without the testimony of expert witness. Example – closing the swab/haemostat left in the abdomen after surgery. Many malpractice cases are triggered by concurrence of a bad medical or untoward outcome and patient’s perception that the physician lacks respect/concern for him as an individual, as a person. Risks of treatment, which varies from patient to patient, must be discussed with a patient while taking consent.

This has led the registered medical practitioner loose their confidence in profession placing himself stand in a situation where he cannot predict when and how he can be booked under the charges of COPRA and asked to pay huge compensation. Something was thus required to fight and regenerate the confidence among the registered medical practitioners to face the consumerism policies and consumerist patients bravely. With Medical Indemnity Insurance (MII) plan insurance companies can provide needful help to a doctor to pay the compensation amount to the patient when legally imposed to pay as penalty for the confirmed charges of medical negligence. This was made available in India only recently since December 1991. The term indemnity means, reimbursement to compensate. This insurance scheme works exactly like Life Insurance Scheme. The insurance company will collect proportionate amount on a monthly/yearly/other convenient modes regularly from a doctor who opts for the plan and help to provide the insured doctor protection against the financial consequences of legal liability in his profession. If the insured is legally liable to pay damages to others, the policy help him by indemnifying him subject to the terms, conditions and limitations of contract. Indemnity is also available in respect of legal costs awarded against the insured as well as legal costs and expenses incurred by the insured with the written consent of the insurers in defence of settlement of claims. Thus, whenever claims arise out of bodily injury or death of any patient, caused by or alleged to have been caused by omission or negligence of medical practitioner, who is covered under the medical indemnity insurance, enjoys the umbrella protection by the company paying compensation to the patient against the legal liability of the member doctor, such as defence cost, fees expenses, etc. Several insurance companies have also introduced facility of individual/joint insurance schemes to single doctor practicing alone or several or all doctors in a hospital or such other organisations recently. In India, currently two insurance companies introduced medical indemnity insurance cover and they are:

Chapter 4: Ethics of Medical Practice

Box 4.2: Nine R’s of malpractice prevention

• Oriental Insurance Company • General Insurance Corporation The amount of premium a doctor has to pay to the company varies depending on the speciality of the doctor. REFERENCES 1. Rao NG. Practical Forensic Medicine. Medical Publishers, Jaypee Brothers, New Delhi, 3rd edn, 2007. 2. Machin V. Churchill’s Medicolegal Pocket Book, 1st edn. Churchill Livingston, 2003. 3. Rao NG. Forensic Medicine: Historical Perspective, 3rd edn. HR Publication Aid, 2001. 4. Rao SKR (Ed). Encyclopedia of Indian Medicine, Historical Perspective, Popular Prakashan, Mumbai, 1985. 5. Dikshit PC (Ed). HWV Cox, Medical Jurisprudence and Toxicology (7th edn) published by Lexis Nexis Butterworths, 2002. 6. World Medical Association Declaration of Sydney on the Determination of Death and the Recovery of Organs, Dated: 14.6.2006, Retrieved on: 21 September 2007, Source: http:// www.wma.net/e/policy/d2_1.htm. 7. Mathiharan K, Patnaik AK. Modi’s Medical Jurisprudence and Toxicology. 23rd edn. Lexis Nexis Butterworths 2005. 8. Rao NG. Forensic Pathology, 6th edn, HR Publication Aid, 2002. 9. Nandy A. Principles of Forensic Medicine. New Central Book Agency (P) Ltd: Kolkotta, 2000. 10. Medical Council of India, Appendix I, 1593, in Gazette of India, (Chaitra 16, 1924, Part – III, Section 4), April 26, 2002. 11. Indian Medical Council (Professional conduct, Etiquette and Ethics, Regulations,) by MCI, Arman–E–Galib Marg, Kotla Road, New Delhi, 2002. 12. Shield JPH, Baum JD, Children’s consent to treatment. BMJ, 1994;308:1182-83. 13. MR Chandran (Ed). Guharaj Forensic Medicine, 2nd edn. Orient Longman, Hyderabad 2004. 14. Committee of Bioethics 1993-94: Informed consent, parental permission and assent in paediatric practice. Paediatrics 95;02:31417. 15. Singhal SK. The Doctor and the Law, 1st edn. MESH Publishing House Pvt. Ltd., 1999. 16. Kaushal KA. Medical negligence and legal remedies with special reference to COPRA, 2nd edn. Universal Law Publishing Co. Pvt. Ltd. 2001.

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Part II: Medical Jurisprudence 44

17. Jagadish Singh, Medical Negligence and Compensation, 2nd edn, Bharath Law Publications, Jaipur, 1999. 18. Justice Cardozo, Schloendroff V. Society of New York Hospital, 1914, cited in Machin V, Churchill’s Medicolegal Pocket Book, 1st edn, Churchill Livingston, 2003. 19. Subrahmanyam BV, Forensic Medicine, Toxicology and Medical Jurisprudence (Simplified and New Look), Modern Publishers, New Delhi, 2004. 20. Hidaytulla M, Sathe SP. Ratanlal and Dhirajlal’s – The Code of Criminal Procedure, Wadia and Co. Pvt. Ltd., Nagpur, 1988. 21. YV Chandrachud, VR Manohar, A Singh. Ratanlal and Dhirajlal’s, The Indian Penal Code (Act No: 45 of 1860 as amended up o the Criminal Law Second Amendment Act No: 46 of 1983, and

22. 23. 24. 25. 26.

Dowry Prohibition Amendment Act No: 43 of 1986, along with State Amendments), 28th edn, Wadhwa and Co. Law Publishers, Agra, 2004. The Transplantation of Human Organ Act, 1994 (No: 42 of 1994, 8th July 1994). Bernard K. Simpson’s Forensic Medicine, 11th edn, Arnold: London, 1997. Medical Liability Mutual Insurance Co., New York, USA, cited in Consumer Forums and Dilemma of Doctors, by Sri V. Harihar Rao and Jaya V. Harihar Rao, Andh WR (Journal), 24, 1995(II). 1998, (6), SCALE 30: 1998 (7) JT 626: 1998 (9) Supreme 39. Consumer Protection Act, 1986, Retrieved on July 11, 2009, Internet source: http:/ncdrc.nic.in/1_1.html.

INTRODUCTION The advances in medical science and technology have undoubtedly brought relief in several health issues to a great extent. This certainly has altered the pattern of human life and its value along with the upsurge of affirmation of human rights, autonomy and freedom of choice. Amongst these issues, one which has assumed global dimensions is the right to a dignified death and the related matter of voluntary euthanasia.1,2 The word euthanasia (derived from the Greek—eu meaning ‘good’ and thanatos meaning ‘death’) raises strong emotions and has become controversial as it involves termination of human life, which has been unjustifiably equated with killing.1 Advocates of euthanasia consider it as producing release from useless, poor quality life, economic drain on hospital, family and family finances, emotional drain, and caring for handicapped newborn or sick and aging parents.2-5 DEFINITION Euthanasia or mercy killing or assisted suicide are synonymous terminologies, defined as painless killing of a person who is suffering from incurable disease, senility, or a permanent damage to brain, which cannot be repaired or cured.6-12 Depending on act of induction and willingness of the patient, euthanasia is classified into four types.1-3 TYPES OF EUTHANASIA Depending on how it is induced, euthanasia could be active or passive euthanasia; while depending on the willingness of the patient, it could be voluntary and involuntary. Active euthanasia (Positive euthanasia): It is an Act of Commission. Death is induced by the direct/indirect action, e.g. by giving a large dose of a drug that hastens death. Passive euthanasia (Negative euthanasia): It is an Act of Omission. Here there is no active intervention to end the life. The doctor stands by ‘passively’, allowing nature to take its course. No specific medicine is given or life supporting measures are provided. Death is induced by the discontinuation of life-sustaining measures to prolong the life in desparate cases, e.g. stopping the heart-lung machine facility for a severely defective newborn infant, or a severe head injury case, etc. Thus, it is refraining from action that would probably delay the death and permit natural death to occur. Voluntary euthanasia: It means euthanasia is induced at the will of an individual by his or her request, e.g. a patient suffering from incurable disease requesting the doctor to terminate his/ her life.

Chapter 5: Euthanasia (Mercy Killing)

5

Euthanasia (Mercy Killing)

Involuntary/ non-voluntary euthanasia: It means euthanasia induced in persons who are unable to express their wishes, e.g. in person with irreversible coma or severely defective infant, etc. Euthanasia is always a controversial topic. While the ethics and religion call against it, medical profession is asking for it. Accordingly as per the ethical and religious views God has made life and God alone should take it. However, the medical view is that in incurable disease conditions one shall not try to kill but need not keep alive also. Though euthanasia is accepted legally in certain parts of the United States, Uruguay, Poland, Australia, Switzerland, it is not yet permitted legally in India. Currently a lot of debate is focused on the pros and cons of validating euthanasia legally.1,2,11,12 Taken singularly the term euthanasia has no practical meaning, and has been qualified by voluntary, involuntary nonvoluntary and other prefixes. Medical practice today is oriented to the prime function of sustaining life at whatsoever cost, irrespective of the quality of life. The physician treats death as an enemy and feels a sense of personal defeat when he fails to avert it. This apprehension of the mind of fighting death, coupled with adherence to outmoded concepts of ethics has led to a mental and emotional block in most physicians towards voluntary euthanasia irrationally equated with killing and sense of murder. Perhaps the fear of the law is also contributing to this mental attitude. EUTHANASIA AND ITS ETHICAL ASPECTS Medical ethics always emphasized the need of preservation of life. Down the ages it has rejected the act of taking away of life. The intentional termination of life of a human being is contrary to the principles and policies for which medical profession stands. This is irrespective of the situation of the patient. Hippocratic oath says: “...neither I will administer a poison to anybody when asked for to do so, nor will I suggest such a course...”.6-12 Thus, all ethical codes reject euthanasia. However, it is also a fact that, medical ethics have never been static. Ethics have been undergoing changes or rather evolution frequently. Medical science and technology have produced an impact, which calls for this re-evaluation and evolution of medical ethics systems.4,11,12 The prime responsibility of the medical professional is to relieve human suffering. To understand the concepts of ethics, voluntary euthanasia should be viewed in this context. Duty of the physician is to treat, to heal and offer an acceptable quality of life to an ailing patient.3,4 45

Part II: Medical Jurisprudence

Above all, it is the relief of suffering by all means available to him. When the end point is reached, death by nature or via the medium of voluntary euthanasia is immaterial. Consequently when euthanasia is the only good medicine available for the patient, what is wrong in implimenting it? A physician need not to hesitate or feel guilty to practice this, as final remedy is for the patient or for the relatives. Accepting the patient’s choice— euthanasia, can certainly be considered as the most intelligent and diligent time-honoured ethics in irremediable conditions or diseases. A physician respecting the existing practice of medical ethics, such as patient’s right to refuse any treatment offered; or at times using doses of pain killer drugs, which may shorten the life— a physician is not transgressing any ethical bounds.4,11 Added to this the patient’s voluntary and informed consent to accept treatment forms all the legal and ethical basis for offering any form of treatment, be it a conservative line of treatment for prolonging life or means of painless termination of life under the banner of euthanasia. A doctor, acting in good conscience, is ethically justified in assisting death which, relieves intense and unnecessary pain or distress caused by an incurable illness, greatly outweighs the benefit to the patient than further prolonging life. This applies to patients whose wishes on this matter are known to the doctor be respected and considered as more significant than any contrary opinions. However, what is incurable today may not be so tomorrow. And therefore there is always an opportunity to reconsider and re-evaluate the indications and re-adopt the same for the ethical rationale as well.3,4,11 INDIAN LAW ON EUTHANASIA As law stands today, no one has the right to do away with life, whether one’s own or that of others, except under certain conditions such as war or after due process of law as punishment.6,8,10,11,12 No one can take away the life of an innocent person. Life is inviolable. Deliberately causing death of another person constitutes a criminal act (homicide), as does co-operating in causing another’s death. The law forbids this. As man has the right to live, does he have the right to die? Can a physician-aid-in-dying? Legal aspects of euthanasia are difficult to understand. The law on euthanasia, though active and legalised in some of the countries globally, it has been sleeping and done nothing till now in India, as euthanasia goes on unhindered behind the closed doors.1-3 The law in 1994 had the first encountre on right to die by way of a petition filed by P Rathinam directed against the constitutional validity of Section 309 IPC, which deals with punishment for attempt to commit suicide. The Supreme Court ruled in favour of the petitioner, and thereby legalizes and permits suicide and rendering as unconstitutional punishment for helping/ abetting of suicide.1 In this case a consequence was drawn between euthanasia and suicide. The judgment stated that in cases of passive euthanasia, the consent of the patient (in sound mental condition) is one of the pre-requisites.1,2 So, if one could legally commit suicide, he could also give consent for being allowed to die. It went on to say that if suicide were held to be legal, the persons pleading for legal acceptance of passive euthanasia would have a winning point. This judgment came as a shot in the arm for people supporting euthanasia. Hence, whatever progress was made, this came to a grinding halt in 1996, and the state of confusion returned. The same

46

court now upheld the constitutional validity of IPC Sections 309 and 306 thereby legalising the same, totally contradictory to the earlier one. This presented a picture of confusion that prevails in our apex judiciary as far as euthanasia is concerned.1,2,12 The basis for this was Article 21, which states that all Indians have a right to life and personal liberty. The judgment accepted the view that in a terminally ill patient (Permanent Vegetative State - PVS), mercy killing does not extinguish life, but accelerates conclusion of the process of natural death that has already commenced. However, it also added that the scope of Article 21 couldn’t be widened to include euthanasia. In the concluding remarks, assisted suicide and abetting of suicide were made punishable, due to cogent reasons in the interest of society.1,2,11 So far there has been no reported case of euthanasia per se, but if it does come up, the prosecution will have a definite advantage. The law as of now is still pretty ambiguous on the topic of euthanasia, but we can hope that some concrete steps shall be taken to resolve this burning problem. REQUIREMENTS OF EUTHANASIA No binding guidelines/ rules are suggested till now, as each individual case must be dealt with on its own merits. However, the requirements as laid out in a judgment of the Nagoya High Court in Japan may be of some aid. Accordingly, what might be accepted ethically are:2,3 • The patient must be suffering from unbearable pain. • The patient’s condition must be terminal with no hope of recovery. • Euthanasia must be undertaken to relieve suffering. • It can only be undertaken at the expressed request by the patient. • A qualified physician must carry out the procedure. • The method adopted must be ethically acceptable. ROLE OF THE PHYSICIAN Besides the above there is a very controversial area where the physician may be called upon to exercise some philosophical and moral judgement. This area is the one concerning means used to terminate life where in doctor has multifaceted role to play. It could be the negative means of allowing death to occur by withholding treatment and the positive means of causing death to occur.2-5 The question posed is whether there is a moral difference between these two means? The borderline is certainly blurred when the patient has made a firm request for euthanasia and the terminal event is not far away. It is difficult to see the moral difference between the two when in both means the doctor has accepted moral responsibility for actions taken. It is misunderstanding to believe we are not terminating life when we withdraw life supports. Will it not be more humane and compassionate to bring about rapid and forceful end by positive means such as suitable doses of narcotics, rather than prolong the process of dying by withdrawing life supports? The role of the physician in voluntary euthanasia is not only desirable but also almost imperative as he can only make several vital decisions. Thus, involvement of a qualified physician is a must to assess several aspects of euthanasia such as: The request by a competent patient, ensure if the request is voluntary, the incurability of the condition from which the patient is suffering, presence of caring at the time of death and a swift painless death.

Extracts from a sample survey of 200 doctors carried out by the Society for the Right to Die with Dignity in Mumbai,2,3 do offer some signs. Accordingly: • Ninety per cent stated they had the topic in their mind and were concerned. • Seventy-eight per cent argued that patients should have the right to choose in case of terminal illness. • Seventy-four per cent believed that artificial life supports should not be extended when death is imminent; but only 65 per cent stated that they would withdraw life supports. • Forty-one per cent argued that living will should be respected. Thirty-one per cent had reservations. • Considerations involved ethics, morality, law and religion in that order of importance. • More than 70 per cent were apprehensive of the abuse of the law if one was enacted to legalise voluntary euthanasia. VOLUNTARY EUTHANASIA AND INDIAN SOCIETY The issues of right to a dignified death and voluntary euthanasia are not the concern of the medical profession alone, and it should not be so if society has to keep a watch over abuse of the concepts. All sections of society must be vitally involved as the issues transcend any philosophical, moral, legal or theological considerations. It is an issue of humanism and compassion. Society will need to change its value systems in the context of the changing medical scenario, of socioeconomic environment, of increasing cost of medical ser vices and their costeffectiveness.2,3

Using knowledge and new power intelligently is better than just adhering to the dogmas and beliefs of the past, which has no relevance for this age of biological revolution and spectacular medical skills. To call ourselves a civilized society, one must understand death, and respect it as much as we respect life. REFERENCES 1. BN Colabawalla. (A) Understanding Voluntary Euthanasia: A Personal Perspective, and (B) Medical Profession vis-à-vis Voluntary Euthanasia Issues in Medical Ethics 1996;4:1. 2. Nikhil Goyal, Spandan. Cover Story on Euthanasia, MAMC, New Delhi, 2000. Website: http://www.spandan.com/index.php. 3. Preston Thomas, Why Aid-in-dying is not killing: A Physician Speaks out, Time- L Jfr News Letter of Hemlock Society 1994. 4. Norita. Six requirements for judgement on Euthanasia. Proceedings of 9th International Conference of World Federation of Right to Die Society 1992. 5. Knight B. Simpson’s Forensic Medicine (11th edn). Arnold: London 1997. 6. Mathiharan K, Patnaik AK (Eds). Modi’s Medical Jurisprudence and Toxicology, 23rd edn. Lexis Nexis Butterworths 2005. 7. JK Mason, Mc Call S. The Donation of Organs and Transplantation’s, Law and Medical Ethics Butterworth: London 1983. 8. Knight B, Sahai VB, Bapat SK, et al. HWV Cox Medical Jurisprudence and Toxicology. The Law Book Co (P) Ltd: Allahabad 1995;232-37. 9. Krishnan MKR. Handbook of Forensic Medicine including Toxicology. Paras Medical Books: Hyderabad 1992. 10. Nandy A. Principles of Forensic Medicine, New Central Book Agency (P) Ltd: Kolkata 2000. 11. Rao NG. Principle and Practice of Forensic Medicine, HR Publication Aid: Manipal, 2nd edn, 2002. 12. Rao NG. Forensic Pathology: HR Publication Aid: Manipal, 6th edn, 2002.

Chapter 5: Euthanasia (Mercy Killing)

VOLUNTARY EUTHANASIA— INDIAN DOCTOR’S VIEWPOINT

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Part II: Medical Jurisprudence

6

Consumer Protection Act and Medical Profession

INTRODUCTION Man is a social and rational animal. Throughout his evolution he has tried to improve upon everything he has laid hands on, anything which he has thought about, everything, which he has invented or discovered. The process of thinking gives birth to self analysis as well as to the factors of coherence among various individuals. One cannot survive alone. Interaction is a must. This symbolises the dynamism of civilisation and the more free and fare it is, the more developed we become. Education, trade and commerce, statecraft, research, international policy – all are forms of human interaction. The most subtle and indispensable interaction exists between two entities, if one thinks of minutely keeping in view of commercialisation of every sphere of life, is the interaction between the seller and buyer, the giver and taker, the skilled one and the beneficiaries—the trader and consumer. Is the doctor-patient relationship a special one? Or like any other commercial transaction? Consumer Protection Act, commonly known as COPRA or CPA came into existence in December, 1986.1 In April, 1992, the National Commission, on appeal from the Kerala State Commission decided that the medical services be covered under COPRA.2 Justice Bal Krishna Erade ruled that the medical services are also covered under COPRA. On November 13, 1995, Supreme Court upheld that the medical services are covered under COPRA. This means a patient (consumer) can make a complaint to a redressal forum in respect of defective service, if the service has been paid for.2 Defective in the context of a doctor’s service means negligent. Deficiency means fault, imperfection, shortcoming or the inadequacy in quality, nature and manner of performance of medical service rendered by a hospital and/or member of the medical profession. Several amendments in the Act have been passed in the Consumer Protection (Amendment) Act, 1993.1,2 Purpose of the Act Thus, the statute has been enacted to provide for better protection of the interests of consumers and for that purpose to make provisions for the establishment of the consumer councils and other authorities for the settlement of consumers’ disputes and for matters connected therewith.1 The complaint is to be lodged before a duly constituted redressal forum for easy disposal of cases instead of following the ordinary course of law which take much time and is much expensive to a poor consumer to get justice. It is important to discuss the various provisions of the Act in the true spirit of the legislation to enable one to contemplate its applicability and equip oneself with a grasp on 48

the subject so that as and when the need arises one may invoke the same. Application of the Act It has been provided in the Act that it shall apply to all goods and services unless otherwise explicitly provided by the Central Government by notification.1 Who is a Consumer? Any person who buys any goods against consideration or hires or avail any services for consideration, which has been paid or partly paid or promised to be paid, is a consumer. For the matter, it also includes any user of such goods where such use is made with original buyer’s approval. However, if the goods are purchased for resale or for any other commercial purposes, then the buyer is not a consumer and cannot avail the protection under this Act. Similarly, any person who hires services against consideration is also a consumer and it includes any beneficiary of such services, of course with the approval of original consumer.1 Thus, any user of goods or beneficiary service has also a legal right and locus standi to initiate action under the Act. On 17 Feb, 1994, the Madras High Court while deciding bench of writ petition in Dr. CJ Subramania vs. Kumaraswamy, I (1994) CPJ 509, interpreted the provisions of Act vis à vis medical practitioners as under:3 • The services rendered to a patient by a medical practitioner/ hospital by way of diagnosis and treatment both medical or surgical, would not come within the meaning of ‘service’ as defined in Section 2(1)(0) of COPRA, 1986. • A patient who has undergone treatment by medical practitioner/or hospital by way of diagnosis and treatment, both medical/and surgical, cannot be considered to be ‘consumer’ within the meaning of Section 2(1)(d) of the Act. • The medical practitioner/hospital undertaking and providing paramedical services of any category or kind cannot claim similar immunity from the provisions of the Act and they would fall, to the extent of such services rendered by them, within the definition of service and a person availing of such service would be a consumer within the meaning of Act. (This issue stands finally decided by the Supreme Court).3 Thus, the Consumer’s Protection Act has created great stir amongst the medical professionals on the ground that it would be extensively damaging to the profession and the public service. Though there are many counter arguments of these feelings of the doctors in profession, it can be said that the Act if ultimately keeps medical service under its purview, then must be enforced with full precaution.4

What is a Complaint? Any allegation in writing made by a complainant is called a complaint. Procedure for Lodging Complaint and Disposal of Cases1,6 The complaint can be lodged at any centre as mentioned below with or without engaging a lawyer and by paying nominal fees of Rs 1.25 (Rupees One and Paisa Twenty-five only). There are three strata for lodging the complaints:

District Level District Forum/District Consumer Dispute Redressal Forum, to be chaired by a district judge and two other members, one of whom should be a man of eminence and good repute and the other a lady social worker. At district level, a claim for compensation towards damages is fixed to a maximum of Rs 1 lakh at the starting which has been enhanced subsequently to Rs 5 lakhs. State Level For cases, where compensation is claimed for more than Rs 5 to 20 lakhs, the complaint should be lodged before the State Commission/State Consumer Dispute Redressal Commission. The state level forum is to be chaired by a High Court Judge and two other members as selected in case of district redressal forum. National Level When the compensation claimed is more than 20 lakhs; the complaint has to be lodged before the national body, i.e. National Forum/National Consumer Redressal Commission. A judge of the Supreme Court, selected by the Union Government (who will act as the President of the forum) with four other members including a lady member, constitutes this body. Proper Procedure This has been deliberately simplified. If there is a defect of goods or deficiency in service then the Consumer or Any Recognized Consumer Association or Central or State Government can file a complaint before the concerned consumer court in the following manner.1,6,8-10 • Complaint has to be filed with any of the three forums, within 2 (two) years from the date of cause of action. • Any appeal preferred from the order of District or the State Commission under the Act, must be filed within 30 (thirty) days of the order. • Admission/no admission: If admitted, opponent is required to file reply within 30 (thirty) days. Under Section 23 of the Act, any person, who is aggrieved by an order made by the National Commission whether in its original or appellate jurisdiction, has a right to prefer an appeal to Supreme Court

• • • • • • •

within a period of 30 (thirty) days from the date of order. The limitation period of 30 days will not stand as a bar, if the Supreme Court is satisfied that there has been a sufficient cause for not filing it in the period. No court fees (even if compensation claimed is in terms of crores of rupees). Four copies of complaint to be filed (3 for court, one for opponent, if there are more than one opponent then so many extra copies). Case is expected to be decided in 90 days (maximum in 150 days). However, no time limit has been laid down by the Act, for the disposal of an appeal or revised petition. Only one adjournment is normally permitted. Presence of lawyers is not compulsory. Both parties can personally present their case. Lawyers can represent them if they so wish. Summons, evidence, principles of natural justice, same procedures as applicable to ordinary courts. So ignoring notices, summons, etc. of these courts also invite contempt, fine, imprisonment, etc.

Penalty1,4,10 In case of dismissal of frivolous or vexatious complaints—it shall be recorded in writing, dismiss the complaint and make an order that the complainant shall pay a penalty to the opposite party such cost, specified in the order, not exceeding Rs. 10,000.00 (Rupees ten thousand). After the introduction of COPRA or CPA 1986, a large number of cases against doctors and hospitals at different levels have been filed and damages rewarded. As per Supreme Court of India on 13 November, 1995, the medical services done on payment basis and /or also done free to those patients who can afford to pay, both come under the ambit of the Act. The judgement also states that when a person has a medical insurance policy and all his charges are borne by the insurance company, the service rendered by the medical practitioner is not a free treatment and would therefore, constitute service as defined in the Act and accountable. Consumers in the country have also won another battle against medical malpractice where in he qualifies one medical system and practices another is considered as quack and a charlatan. Supreme Court has upheld the right of the consumer to haul-up such quacks before the Consumer Courts.

Chapter 6: Consumer Protection Act and Medical Profession

Rights of a Consumer1,5,6,8-10 As per Consumer Protection Act, a consumer has following six rights being a consumer of a service obtained by him on payment of charges towards or an item bought by him paying its cost: 1. Right to safety 2. Right to choose 3. Right to information 4. Right to education 5. Right to be heard 6. Right to seek redressal

Acts and Apprehensions in Medical Profession The medical practitioners in general found reasons to be apprehensive for fear of its misuse and the obvious and unavoidable turmoil it may create in the whole profession. The reasons of apprehension are that:8-10 • This act will totally disturb the doctor-patient relationship. • Medical practitioners may opt Defensive Medical Practice – i.e. the Act will impose an undesirable tendency in doctors, particularly in general practitioners and in new graduates to be more evasive of their responsibilities towards their patients and refer more number of cases to consultant specialists and to advise extensive laboratory investigations which will make their position comparatively safe without the improvement of clinical mind and experience thereby making the treatment for general population to be costlier, even unto the extent of being beyond the reach of many. • Another apprehension is that the doctor will develop a tendency to assure himself or herself free from the danger 49

Part II: Medical Jurisprudence

Table 6.1: Comments and countercomments on COPRA Arguments by doctors 1. Professionals are exempt under contract of personal service 2. There are civil courts, hence, no need of consumer courts 3. As there is no court fee, etc. any one can appeal here, increasing the litigation and wasting valuable time and energy of Dr and cases. 4. Consumer courts are manned by nonmedical people. How can they understand and decide technical matters? 5. The cases are hurried through because of time limits. 6. Indian Medical Council and State Medical Councils are there. Patient can complain of negligence to these bodies.

7. A doctor would be punished thrice for the same offence by: a. Consumer courts b. Civil courts c. Medical council 8. No doctor would take risky cases for fear of increased litigation. 9. Doctors would resort to defensive practice and all unnecessary investigations increasing the cost of health care. 10. Doctors are practising a profession, not commerce.

11. It would lead to a loss of trust and faith between doctor and his/her patient. A doctor starts seeing a potential litigant in each of his or her patients

Counterpoints It is contract for service and not contract of service Civil courts have failed in delivery of justice at less expenses. Consumer courts also follow principles of natural justice may sort out frivolous

Doctors are already being tried by civil courts, for compensation claims. While they are willing to appear before a magistrate in civil court, it is surprising why they oppose appearing before a more senior but retired Judge in Judges in a Consumer Court Both parties can produce their own evidence, lawyer, expert. Frivolous adjournments are not allowed to prevent the delay a. They can try only cases of infamous conduct. b. They can only punish doctors by withdrawing registration. c. They have no power to award compensation d. They are all doctor bodies—so do not inspire confidence in patients e. Virtually all professions have their own national bodies and just on this they cannot be exempted No Consumer Court is additional facility It is consumer choice to go to consumer court or civil court once case is decided by consumer court, he/she cannot be punished for the same offense by a civil court (Res judicata). Medical council has an entirely different role to decide infamous conduct. Failure of treatment or error of judgment is no offence. All principles of natural justice are followed like in civil courts. This is only partly correct. What is expected is only a reasonable care and skill, not the best care and skill. So, if you maintain contemporary standards nothing to fear. There is commerce in all profession. Medicine is no exception. When medical profession is going to the extent of forming corporate bodies, how commercial angle can be denied. And with commercialism there is bound to be consumerism. With fall in the ethical standards and increasing commercialism there is already a certain degree of loss of faith. In fact due to CPA if doctors become more conscious about their knowledge, ethics and standard of practice some of the faith lost can be regained.

of paying compensation by surrendering to the different professional indemnity society/insurance firms which are bound to crop up to make a good business, taking advantage of this situation. • As a consequence to what will happen as described above, the treating physician will charge from the patients more than what they charge presently. How the Doctors in General should Deal with the Problem if the Profession is kept within the Purview of CPA (1986)? The argument by the medical professionals is that:5,8-10 • The present law of the land is not deficient in dealing with the erring doctors. • An erring doctor should be accountable for his or her Negligent Act. • A Negligent Act of doctor may come under the purview of Cr PC and IPC, should continue to be dealt in the same way. • The civil courts are there to take up less severe negligent cases which can be compensated by money. • Medical Council of India and State Medical Council are there to deal extensively with the misconduct and unethical practice of a registered medical practitioner. 50

The counterargument by the proact lobbies is that:9,10 • The time consumed in taking decision in a court of law concerning payment of compensation to the aggrieved patient is too long and is expensive too. • The common consumer of medical service should be given some relief by way of providing an alternative redressal forum for their grievances. • The other argument of this section is that the Medical Council (State and Central) being bodies of the doctors themselves may have some natural pardoning tendency for the faulty doctors. Apart from this, many of the state medical councils are defunct or slow in their action. Thus, generally speaking, justice remains far from the reach of the patients who suffer from the Negligent Acts of the doctor. • While presenting their case on different platforms, doctors have expressed various apprehensions and reservations about COPRA, 1986. However, majority of those arguments look misplaced and only a few sound genuine. Table 6.1 presents the comments and counter comments of the Act.8-10 CONCLUSION Considering the arguments and counterarguments above (Table 6.1) in this respect, following conclusions can be drawn.

Let the profession utilize CPA as a challenge to increase the standard of medical care in general and make the government realize its responsibilities like improving the facilities in the government hospitals, reduce patient congestion, etc. Remember, the old saying: Prevention is better than cure. Let us do some introspection and reaffirm that we shall stand by the hippocratic oath and the Code of Medical Ethics. That would go a long way in winning over the patient’s confidence and faith, in preventing litigation and also salvaging our lost nobility and reputation of Vaidyo Narayano Hari to some extent. REFERENCES 1. Kaushal KA. Medical Negligence and Legal Remedies, with special reference to COPRA, 2nd edn, Universal Law Publishing Co. Pvt. Ltd, 2001. 2. Subrahmanyam BV. Modi’s Textbook on Medical Jurisprudence and Toxicology, Oxford Press, New Delhi, 2000. 3. In VP Shantha’s Case: Indian Medical Association vs VP Shantha, III (1995) CPJI (SC): 1995(3) CPR 412: 1995 (6) SCALE 237: 1996 CCJ I (SC). 4. MR Chandran (Ed). Guharaj Forensic Medicine, 2nd edn, Orient Longman, Hyderabad, 2004. 5. Singhal SK. Singhal’s Forensic Medicine and Jurisprudence, The National Book Depot, Parel, Mumbai, 2003. 6. Singhal SK. The Doctor and Law, The National Book Depot, Parel, Mumbai, 1999. 7. Mathew J. Medical Confidentiality and AIDS: Law and Medicine 1995;1:60. 8. Rao NG. Forensic Pathology, 6th edn, HR Publication Aid, Manipal, 2002. 9. Rao NG. Practical Forensic Medicine. 3rd edn, Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, 2007. 10. Rao NG. Principle and Practical of Forensic Medicine. 2nd edn, HR Publication Aid, Manipal, 2002.

Chapter 6: Consumer Protection Act and Medical Profession

• Medical councils can be reactivated and can be made more effective by allowing them to decide compensation to the aggrieved patient, by the erring doctors. • The fact is that the Act of Negligence and Misconduct of a doctor can be better appreciated and assessed by members of medical profession alone. However, inclusion of members from other concerns of the society in the medical council is desirable and no case can be just skipped off without application of mind and attention. • Doctors like all other members of the society should be accountable for their works, particularly because they deal with life and death issues of other members of the society. • All the while, as argued by the doctors there is nothing wrong in inclusion of few medical men in the consumer redressal forum as members, particularly when a case of therapeutic controversy is to be taken up. • If the government and the society think that the present legal system is not sufficient to deal with the negligent doctors, they should make provision of infallible judgements from medical point of view. • In whichever forum the Negligent Act of a doctor is tried, provision must be made for inclusion of members of medical profession in it. • Effort must be also made to provide compensation to the doctor when he/she is proved to be non-negligent, by the complaining party. • The cases of alleged negligence should not be made public through media and press so as to hamper the professional life of the doctor, as the case may ultimately be proved to be a mistake of facts without any indication of any wrong by him/her.

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Part II: Medical Jurisprudence

7

Human Organ Transplantation: Legal and Ethical Aspects

INTRODUCTION The Transplantation of Human Organs Bill, 1994, provides for the regulation of removal, storage and transplantation of human organs for therapeutic purposes, and for prevention of commercial dealing of human organs and for matters connected there with or incidental thereto. 1,2 It has been called as Transplantation of Human Organ Act, 1994, and came into effect from February 04, 1995, with Government of India Gazette notification. With the Act coming force, brain death has acquired legal status in India. The Act also caused the Ear Drums and Ear Bones Act, 1982, and the Eyes Act, 1982 to be repealed.1 Though human tissues or organs, anatomically speaking are of several types, medicolegally they are of only two types:3-6 1. Regenerative 2. Nongenerative. Regenerative Tissues or Organs Regenerative tissues or organs are human tissues or organs, which, even if removed from their respective places in the anatomy, have the capacity to rejuvenate or replicate within the body.

Examples Blood, semen, bone marrow, skin, etc. which are regenerative in character. So, in effect if a man or woman donates blood or semen (in the case of man) or other regenerative tissues or organs or body substances, he/she does not stand to lose anything as these tissues or bodily substances have in them an inherent quality to regenerate within the body. Nongenerative Tissues or Organs On the other hand, nongenerative tissues or organs such as kidney, heart, lung, liver, etc. if removed from human body will not be regenerated. As a result, in donation of such tissues or organs, the donor undoubtedly, loses a vital organ in the body, which in some cases may result in permanent partial disablement or may even lead to the donor’s death.

52

Concept of Living and Cadaver Donors At this juncture, an explanation as to cadaver donations seems very necessary. This is because doctors and surgeons are now turning to donors who are brain dead. Medical research and technological development have enabled medical practitioners to put patients on an artificial respiratory system or a ventilator, as it is popularly called. By this process, the person’s organs such as the heart and lungs continue to work, while the brain of the person is irreversibly

dead. Thus, the concept derives also the terminology “beating heart donor’s” for the reasons that the organs can be removed from such brain dead patients who are declared dead but kept ventilated and circulated with oxygenated blood by ventilator and such other artificial means. THE TRANSPLANTATION OF HUMAN ORGANS ACT, 19941-5,7,9,10 The proliferation of human organ trade for the purposes of transplantation during 1970s and 1980s has influenced World Health Organisation (WHO) to develop a set of guiding principles on human organ transplantation. Accordingly, it has been resolved that, organs and tissues may be removed from the bodies of deceased and living persons, for the purpose of transplantation only in accordance with the following guiding principles: • Organs may be removed from the bodies of deceased persons for the purpose of transplantation, if: – Consent required by law is obtained, and – There is no reason to believe that the deceased person objected to such removal in the absence of formal consent given during the person’s lifetime. Physicians determining that the death of a potential donor has occurred, should not be directly involved in organ removal from the donor and subsequent transplantation procedures, or be responsible for the care of potential recipients of such organs. • Organs for transplantation should be removed preferably from the bodies of deceased persons. However, adult living persons may donate organs; but in general, such donors should be genetically related to the recipients. Exceptions are regenerative tissues. • An organ may be removed from the body of an adult living donor for the purpose of transplantation if the donor gives free consent. The donor should be free of any undue influence and pressure and sufficiently informed to be able to understand and weigh the risks, benefits and consequences of consent. • No organ should be removed from the body of a living minor for the purpose of transplantation. Under national law exceptions may be made in the case of regenerative tissues. • The human body and its parts cannot be the subject of commercial transactions. Accordingly, giving or receiving payment (including any other compensation or reward) for organs should be prohibited. • Advertising the needs for or availability of organs, with a view to offering or seeking payment, should be prohibited.

Restrictions of Removal and Transplantation of Human Organs1,2,5,6 Transplantation means the grafting of a human organ from any living or deceased person to some other living person for therapeutic purposes. Any part of human body consisting of a structured arrangement of tissues, which if wholly removed, cannot be replicated by the body, is known as human organ. Fundamentally speaking, this Act seeks to prohibit transplantation of human organs, except in accordance with the procedure envisaged by the Act. In this regard, Section 9(1) mandates that, no human organ removed from the body of a donor before his/her death shall be transplanted into a recipient unless the donor is a near relative of the recipient. A near relative means spouse, son, daughter, father, mother, brother or sister. Where any donor authorises the removal of any of his/her organs after his/her death, the human organ may be removed and transplanted into the body of any recipient who may be in need of such organ. If a donor authorises the removal of any of his/her organs before his/her death and then transplantation into the body of a recipient, who is not a near relative, by reason of his/her affection or attachment towards the recipient or for any other special reasons, such human organ shall not be removed and transplanted without the prior approval of the authorisation committee. The Act enjoins upon the State Government to constitute one or more authorisation committees for this purpose. On an application jointly made by the donor and the recipient, the committee, after conducting a detailed enquiry, subject to compliance of various conditions, may grant approval for the removal and transplantation’s, by giving valid reasons. Authority for the Removal of Human Organs1,5,9,10 A donor may authorize the removal, before his/her death, of any human organ of his/her body for therapeutic purposes. If, at any time before his/her death a donor had, in writing and in the presence of two or more witnesses (at least one shall be a near relative), unequivocally authorized for the removal of his/her organs, for therapeutic purposes, the person lawfully in possession of the dead body of the donor, unless he/she has reason to believe that the donor had revoked the authority, may authorize such removal. In the absence of any such authority, the person who has lawful possession of the dead body may authorise removal, provided if it does not result in any kind of objections from kith and kin, if any, of the deceased.

Where a human organ is to be removed from the body of a person who has suffered brainstem death, the removal shall be undertaken only when a board of medical experts consisting of the following certifies such death: • The registered medical practitioner incharge of the hospital in which brainstem death has occurred. • An independent registered medical practitioner, who is a specialist, to be nominated by the registered medical practitioner in clause (i), from a panel of names approved by the appropriate authority. • A neurologist or a neurosurgeon to be nominated by the registered medical practitioner specified in clause (i), from a panel of names approved by the appropriate authority. • The registered medical practitioner treating the person whose brainstem death has occurred. In the case of a person who is less than 18 years of age and whose brainstem death takes place, the parents of such person may authorise the removal of any organ. However, it is to be noted that, if any inquest is to be held on the deceased person, no authorisation can be granted in such cases. In the case of unclaimed bodies (those who have not been claimed by near relatives within 58 hours from the time of death, either from hospital or prison), the authority to remove any organ is vested in the hands of a person of such hospital or prison, who is empowered by the management in this regard. In the case of a dead body that has been sent for postmortem examination, the person competent (as notified by the State Government) may authorise, the removal of organs for therapeutic purposes, subject to formalities as notified by the State Government. Section 7 mandates that, after the removal of any human organ from the body of a person, the registered medical practitioner shall take adequate steps for the preservation of the human organ.

Chapter 7: Human Organ Transplantation: Legal and Ethical Aspects

• Physicians and other health professionals are prohibited from engaging in organ transplantation procedures if they have reason to believe that the organs concerned have been the subjects of commercial transactions. • Any person or facility involved in organ transplantation procedures is prohibited from receiving any payment that exceeds a justifiable fee for the services rendered. In the light of the principles of distributive justice and equity, donated organs should be made available to patients on the basis of medical need and not on the basis of financial or other considerations. • In tune with the international understanding, the Indian Parliament has enacted The Transplantation of Human Organs Act, 1994.

Regulation of Hospitals1-8 From the date of the commencement of the Act: • No hospital, unless registered under this Act, shall conduct, or associate with, or help in, the removal, storage or transplantation of any human organ. • No medical practitioner or any other person shall conduct, or cause to be conducted, or aid in conducting by himself/ herself or through any other person, any activity relating to the removal, storage, or transplantation of any human organ at a place other than a place registered under this Act. • No place including a registered hospital shall be used by any person for the removal, storage or transplantation of any human organ, except, for therapeutic purposes. Offences and Penalties1 According to Section 18, any person who renders his/her services to or at any hospital, for purposes of transplantation, or conducts, or associates with, or helps in any manner in the removal of any human organ without authority, shall be punishable with imprisonment for a term which may extend to five years and with fine which may extend to ten thousand rupees. If such person is a registered medical practitioner, his/her name shall be reported by the appropriate authority to the respective State Medical Council for taking necessary action including the removal of his/her name from the register of the council for a period of two years for the first offense and 53

Part II: Medical Jurisprudence 54

permanently for the subsequent offense. In addition to this, Section 19 deals with, whomsoever: • Makes or receives any payment for the supply of, or for an offer to supply, any human organ. • Seeks to find a person willing to supply for payment, any human organ. • Offers to supply any human organ for payment. • Initiates or negotiates any arrangement in involving making of any payment for the supply. • Takes part in the management or control of a dead body of person, whether a society, firm or company whose activities include any of those mentioned in the clause. • Publishes or distributes or causes to be published or distributed any advertisements in this regard, shall be punishable with imprisonment for a term which shall not be less than two years but which may extend to seven years and shall also be liable to fine which shall not be less than ten thousand rupees, but may extend to twenty thousand rupees. However, in the light of special and adequate reasons, if any, the sentencing judge may award less than two years imprisonment. So far as the cognizance of the alleged offense is concerned, no court shall take cognizance except on a complaint made by: • The appropriate authority or any authorized officer or • Any person who has given notice of not less than 60 days to the appropriate authority. • The legislative effort in combating this kind of exploitative commercial trade, seemingly, appears to be quite comprehensive.

However, whether the implementation of this would result in distribution or availability of human organs on the basis of medical need or is not difficult to assess as of now. In addition to passing a skeleton piece of legislation, primarily, it is expected of all the states to pass resolutions and the appropriate government must notify the relevant rules, without any further delay, as mandated by the Act of 1994. REFERENCES 1. The Transplantation of Human Organ Act, 1994 (No: 42 of 1994, 8th July 1994). 2. The Transplantation of Human Organ Act, 1994, Amendment, as passed by House of Parliament Rajya Sabha, on May 05, 1983, Lok Sabha on June 14, 1994; Amendment made by the Lok Sabha agreed to by Rajya Sabha on June 15, 1994. 3. Mathiharan K, Patnaik AK. Modi’s Medical Jurisprudence and Toxicology. 23rd edn. Lexis Nexis Butterworths. 2005. 4. Joga Rao SV, Ayyappa CP. Human Organ Transplantation Act, 1994, Law and Medicine 1995;1:73. 5. Xirsagar S. Organ transplantation—an overview of issues: In Sahani A (Ed): Legal Aspect of Health Care ISHA: Bangalore, 160, 2000. 6. JK Mason, Mc Call S. The Donation of Organs and Transplantation’s, Law and Medical Ethics Butterworth: London, 1983. 7. Nandy A. Principles of Forensic Medicine, New Central Book Agency (P) Ltd: Kolkata, 2001. 8. Rao NG. Forensic Pathology HR Publication Aid: Manipal, 5th edn, 1998. 9. Rao NG. Principles and Practice of Forensic Medicine, HR Publication Aid, Manipal, 2nd edn, 2002. 10. Chandran MR (Ed). Guharajs Forensic Medicine, 2nd edn, Oriental Lungman, Hyderabad, 2004.

INTRODUCTION The unexpected appearance of opportunistic infections and an aggressive form of Kaposi’s sarcoma amongst apparently healthy homosexual men and intravenous drug abusers, heralded in 1981, the recognition of a new disease known as the Acquired Immunodeficiency Syndrome (AIDS).1 Immunodeficiency is the hallmark of AIDS. Ever since 1981, as the incidence and awareness on AIDS increased among the public, the ethical, legal and regulatory mechanisms are becoming more significant. Efforts to protect individual rights while safeguarding the public from a fatal communicable virus are presenting many unprecedented legal questions on public health, education, employment, insurance, medical law, family law, civil rights, etc.2-7 An attempt is made here to discuss briefly on ethical and legal aspects of AIDS in the context of developed countries like UK and USA and a developing country like India. ENGLISH LAW2,3 Addressing the question of conflicting public interests, it was held that courts would restrain breach of confidence unless there is a just cause or excuse for breaching confidence.7 However, the duty to disclose information to persons in close proximity of the HIV-infected persons and other patients suffering from contagious diseases has been considered as qualified defense in both USA and UK. The British Medical Council has passed a resolution in 1991 that no physician shall undertake mandatory testing of blood unless expressed consent (refer chapter Consent) has been given by the patient. If the physician does so, he/she is liable for disciplinary proceedings where he/ she should justify his action. This is very relevant especially in the context of unemployment problem faced in England today. Almost all corporations in England insist on HIV test certificate to be given by in-house doctors. Therefore, the British Medical Council (BMC) sought to reinforce the view held earlier by medical experts in UK that there is little justification in law for disclosing to an employer that an employee has AIDS or is HIV positive. US POSITION2-4 Medical confidentiality has been statutorily recognised in several US federal laws. They offer privacy protections to public health records containing HIV-related information. Also, a proposal, which would bring all medical records containing HIV-related data under protection, has received significant attention in Congress.

Health professionals and public health officials have endorsed this. This proposal was incorporated into the public health and welfare code, which talks of AIDS, where strict confidentiality has to be maintained with respect to all information connected with HIV-related diseases and patients. The Florida Supreme Court has recognised the damaging effect of such disclosure of confidential information on public health policy by deterrence. The issue was one of blood donation. The court held that as the populations of HIV-infected individuals grow large, the importance of confidentiality both in and out of the courtroom increases. Much emphasis is not being given with respect to US decisions because of the abundance of case laws in both quarters. To be specifically noted are a few decisions made by the Supreme Court, USA that upheld the views of recognition of right of informational privacy. Thus, a subpoena request for identity of a school child with AIDS was rejected in part because of reliance on state and city confidential laws. Therefore, even in the United States, the health officials have recognised that protection of sensitive information gathered during tracing would encourage participation and cooperation by eliminating the fear of embarrassing and damaging disclosures. The ultimate object of such contact tracing is testing and counseling to provide public health benefits. Furthermore, failure to provide adequate safeguard to protect such information, they are aware, will certainly discourage voluntaries.

Chapter 8: Ethical and Legal Aspects of AIDS

8

Ethical and Legal Aspects of AIDS

INDIAN POSITION2,3,5 The existing AIDS law in India consists of State Amendments and a proposed Central Bill. In August 1989 a bill was proposed in the Parliament called the AIDS (prevention) Bill. • Section 4 of the said bill mandates every registered physician to report each case of HIV positive patient to the health authorities, but does not provide a confidentiality clause. • Section 7, however, requires health authorities to undertake counseling, health education and specialized treatment. But this is of no avail if confidentiality is not guaranteed. • Section 5, talks of precautionary measures to curb the spread of disease. • Section 5(c), suggests removing the patient to a hospital or such other place “for special care”, all at the direction of health authority. Therefore, isolation is a proposed alternative. This piece of legislation was sought to be repealed after vehement protest from Human Rights Groups and the WHO. 55

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Most of the local municipal laws, public health laws as well as the Epidemic Disease Act, 1897, Section 2, says that the State Government is empowered if it is satisfied that the State or any part thereof is visited or threatened with an outbreak of any dangerous epidemic disease, to take measures which it thinks fit and prescribe temporary regulations which would have to be followed by public or any class of persons, necessary to prevent such outbreak and spread of such disease. Under this Central Legislation, Goa, Maharashtra, Orissa and Karnataka have sought to incorporate provisions relating to AIDS within the scope of local acts. Examples • In Maharashtra, Section 421 of Mumbai Municipal Corporation Act requires every doctor to notify the existence of any dangerous disease. • In Goa Public Health Act, according to Section 53(1)(iv) no person including a foreigner can refuse blood collection if the Health Officer has reason to believe that such person is suffering from AIDS or other infectious diseases. • In Karnataka, certain hospitals have isolation wards pertaining to HIV-tested positive people. The local Public Health Act in Karnataka talks of mandatory testing of all women who are admitted into remand homes in the State. ISSUES RAISED With AIDS there are three basic issues raised2-4 and they are as follows:2-4 • AIDS being a disease with no cure/no remedy, what is the status quo of confidentiality with it? • AIDS if considered as contagious and dangerous then why is it not a notifiable condition? • AIDS if not considered as statutorily notifiable, is it constitutionally valid to deal it under Epidemic Diseases Act? To begin with, one must identify whether AIDS is a contagious condition or not. It is not appropriate to use the term contagious. AIDS is a disease communicable from one person to another in specific context only, i.e. by sexual contact or through blood. Hence, it is not transmitted through air, water, belongings or other usual agents. Therefore, HIV is a communicable disease. The logical deduction to this would be that AIDS is not an epidemic disease, neither it is contagious, nor it can be cured or restrained from further spread by isolation and such measures. Therefore, it is submitted here that all legislative efforts in this regard are constitu-tionally invalid. At this juncture, it would be pertinent to make mention of two policy responses prevalent in the world today that tackle the problem of AIDS:2,3,4 • Isolationist response • Integrationist response. Isolationist Response Isolationist response is adopted by Cuba and Romania and includes two specific features: • Mandatory testing • Isolation of infected victims. Though both of these policies adopted are encouraging, the inevitable defects observed with these are: • The approach of mandatory testing is neither feasible nor economically viable in a country with a population of more than 900 million.

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• This means that such mandatory testing is going to be confined to the high-risk groups. The HIV is not related to sexual preferences but to unsafe sexual practice, and such testing on this group is going to reinforce strong prejudice against them. • This will lead to entire high-risk group going underground. There will be failure in disclosing the ailment for the fear of discrimination. This will defeat the object of approach. Integrationist Response Integrationist response is proposed by WHO, and adopted by USA and UK and includes three specific features:2 1. No compulsory testing 2. Protecting through confidentiality 3. Ensuring nondiscrimination against them. These policies are considered to be more encouraging for the merits prevalent in them, which are: • Right to information about HIV tests being conducted and its implication. • Right to refuse to undergo HIV test. • Confidentiality about HIV status of the person who has undergone the test. • Right against discrimination in employment. It is better to examine another issue, viz. private interest vs. society interest. How is such balancing possible and in whose favour is it? Nonprotection of confidential information relating to HIV-infected persons involves a public interest, the interest of society to be warned of him/her, his/her antibody status so that no other person is encouraged to having sexual relationship with him/her. Here the privacy of the individual suffers. On the other hand, protecting confidential information serves two interests: 1. The interest of person (his/her privacy) is protected. 2. The public interest is also served by not disclosing such information. If it is disclosed, people will stop taking such tests, for the fear of social stigma, loss of employment, etc. Nonprotection serves a public interest, but fails to protect an individual interest. On the other hand, protection serves two interests public and private. So, protection of confidential information will necessarily serve a better interest at large. It is relevant at this juncture to explain that confidentiality clause is therefore essential given the circumstances of an HIV-positive person. Earlier attempts such as the 1989 Bill was withdrawn due to protest from human rights group and WHO, who vehemently count down the practice of isolation. India has not on policy resolved to undertake the integrationist response, but it has not sought to back it up by way of legislation till date. REFERENCES 1. Mathiharan K, Patnaik AK. Modi’s Medical Jurisprudence and Toxicology, 23rd edn. Lexis Nexis Butterworths. 2005. 2. Progress Report—Global Program on AIDS, World Health Organisation, Geneva, 1992. 3. Sahani A, Xirsagar S. HIV and AIDS in India: An Update for Action, ISHA: Benguluru, 1993. 4. Mathew J. Medical Confidentiality and AIDS: Law and Medicine 1995;1:60. 5. Dikshit PC (Ed). HWV Cox, Medical Jurisprudence and Toxicology (7th edn) published by Lexis Nexis Butterworths, 2002. 6. Saukko P, Knight B. Knight’s Forensic Pathology. 3rd edn. Oxford, England: Oxford University Press, 2004.

INTRODUCTION Medical records comprise of various documentary reference of the care and treatment particulars provided to the patient.1,2 It is the only valid data available regarding the patient treated by the health care professional, either as a general practitioner or as a hospital-based medical officer, irrespective of whether private or government origin. It is mandatory that all health care professional should maintain the medical records of the patient examined/and treated by them on outpatient basis or as an inpatient case admitted in the hospital. Such records not only are obligatory in the interest of adequate medical care, but they may also be called upon in the court of law, later on for evidence. Thus, the medical records encompass routinely the who, what, where and when of the patient care in the hospital. Customarily, there is a separate department in most of the hospitals with trained/qualified personnel maintaining these formalities. Such department is called Medical Record Department, often referred to as MRD. CONTENTS OF MEDICAL RECORDS The medical records should contain the following:1,4 • Particulars of the patient, e.g. name, age, sex, address brought by (name of the person who has brought him to the hospital), referred by, etc. • Date and time of arrival and examination in hospital. • Date and time of admission and discharge from hospital. • The present complaints by the patient at the time of arrival. • Relevant past history. • Relevant family history. • Relevant personal history. • Details of physical examination done by the physician and the findings. • Laboratory examinations and other investigations adviced for and their reports, e.g. blood sugar, blood urea, X-ray, etc. • Treatment given. • Duly completed consent form for each and every procedure/ s and operation/s performed. • Prognosis chart. • Details on cross consultations/references to other specialist doctor/s and his/their opinions and reports. • In case of discharge from hospital—the condition at the time of discharge. • Maintain discharge card with discharge summary providing brief information on admission particulars, investigations done, treatment given and follow-up advices given at the

• • • •

Chapter 9: Medical Records

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Medical Records

time of discharge to the patient. If the patient is referred by a family physician a copy of the same may better be marked to him as well with all instruction to be carried out by him on discharge from the hospital. If the discharge is against medical advice (AMA), then record accordingly and take signatures of patient and/or his/her guardian/relative with whom patient leaves the hospital). Copy of Police Intimation Letter with all details of information given to the police in every medicolegal cases (at admission and/discharge on recovery/on death of the patient). In the case of death, note down the cause, date and time of death. Name and signature, address, medical council registration number/license of doctor.

In Medical Cases In addition to routine contents mentioned above, certain additional precautionary measures are to be observed in all medical cases and they are:1,4 • The casualty MO must ensure that all the registers are numbered and duly certified. • All pages of the record should be serially numbered. • On all pages, laboratory reports and X-ray plates, word MLC should be marked. It should be so even on requisition for laboratory investigations and X-ray. • All the entries should be correct and in detail and in sequential order. • Abbreviations should be avoided. • All corrections done should be initialed. • All medicolegal documents should be prepared in duplicate. • All communications with police should be in writing only and copy of all such correspondence should be attached to the case papers/file. • There is no time limit as to when the medicolegal case records can be destroyed by the hospital. • All records should be kept under lock and key. • All entries in hospital papers should carry the signature and name of the doctor concerned. Property Rights of Medical Records The medical records and also X-ray plates are property of the hospital.1,2,4 The patient buys the expertise and the treatment rather than the hospital records and the X-ray films. All records are kept in the hospital for the benefit of the patient, doctor and the hospital. In no situation does a patient own his/her records, though he/she has a legal right to the use of the information contained therein.2,3 57

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Patient’s Rights Usually, the patient is given a copy of the investigation reports, treatment advised and the discharge summary. Patient has the right to know the details in his/her records and is entitled to get a copy of his/her hospital record on discharge, on payment of cost of reproduction. In case of death of the patient the next of kin can have the hospital records. However, if in the opinion of the doctor, making the records available to the patient would be harmful or dangerous to patient (professional or therapeutic discretion); he/ she may avoid issuing the records to the patient. The records cannot be used by the hospital or the doctor, for publication, without the patient’s consent. Medical Records in Court When the hospital/doctor have been summoned by the court, requesting for production of the case records, they have to be produced before the court without failure.1,4 The court may require the medical records in all alleged criminal cases such as assault, burns, criminal abortion, dowry deaths, injury, murder, poisoning, rape, suicide, and vehicle accidents, etc. In some of the civil cases also medical records may have to be procured by the court. Workman’s compensation cases, insurance claims cases, malpractice/negligence suits, cases of “contested Will”, disputed paternity cases, etc. constitute some of the examples of civil cases required by the court.4 Information about the health of a patient given to the law courts is covered under privileged communication and the doctor in immune to the charges of breaking professional secrecy under such circumstances.1,2 However, hospital should arrange for photocopying every page of the case file prior to taking them to the court, as the court usually retains the records.1,4 Whenever court needs the document to be retained, hospital doctor should demand a receipt from the court specifying clearly the total number of pages withheld by the court. Submission of Records to Government and Other Agencies On several occasions’ government and other agencies such as LIC place a request to supply the information about a patient

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treated in the hospital. As per law, they are not entitled to this information without the written consent1,2,4 of the patient and hence the hospital should not comply with such requests. However, information about name, age, sex, date of admission and date of discharge, etc. can be given as these are not confidential. Storage and Disposal of Medical Records Storage and disposal of medical records is an essential matter for every hospital. Ever since computerisation, medical records have become simple. Data can be fed into the computers and preserved easily in computer files or on CDs and using CD writer. Such documents can be preserved for any length of time as CDs require minimum space for preservation unlike hard copies/ printed or typed documents of a case. However, following scheme is usually adopted in different types of cases:1 • Nonmedicolegal Cases (Non-MLC) – The OPD records have to be preserved for a minimum of 3 years, when they can be destroyed. – The IPD records have to be preserved for a minimum of 5 years. • Medicolegal Cases (MLC) – There is no specified time limit and hence they cannot be destroyed and must be made available as and when needed. Medical Records and Research It must be remembered here that no medical records can be prearranged or provided to any of the research workers without prior written consent of the patient and an approval of hospital ethical committee. REFERENCES 1. Singhal SK. Medical Ethics and Consumer Protection Act. Jaypee Brothers Medical Publishers (P) Ltd., 2002. 2. Kaushal KA. Universal’s Medical Negligence and Legal Remedies, 2nd edn, Universal Law Publishing Co. Pvt. Ltd., 2001. 3. Poona Medical Foundation Ruby Hall Clinic vs Marutira L. Tikare, 1(1995) CPJ 222 (NC): 1995 (1) CPR 661. 1995. 4. Rao NG. Legal Aspects of Health Care, 1st edn, HR Publication Aid, Manipal, 2001.

INTRODUCTION Anaesthesia has its own special dangers. Anaesthetists, along with surgeons presents a common target for litigation: The actual administration of anaesthetic is not usually the cause of complaint, but the many ancillary responsibilities such as transfusion, injections, airways, intravenous catheters, diathermy, and hot-water bottle burns may form grounds for allegation of negligence.1-5 In recent years, claims of awareness under anaesthesia have become a frequent complaint. One of the most tragic and expensive anaesthetic mishaps is the production of cerebral damage from hypoxia due to failure to maintain oxygenation during the operation. Inattention on the part of the anaesthetist is a more common cause than failures of equipment and recent surveys have shown that inexperienced junior anaesthetist is a major cause of problems. Majority of the operations require the administration of anaesthesia to the patient. This being a complex and special procedure demands special knowledge and experience. As far as possible the anaesthetist should be an expert. He should examine the patient properly prior to the surgery. He should also plan and prepare for administration of anaesthesia depending on the surgery. A written informed consent from the patient or his/her guardian must be obtained in advance. A great variety of unfortunate events/mishaps can occur during or following the administration of anaesthesias and operative or investigational procedures. These do not necessarily convey an error of judgement or negligence on the part of the surgeon or the anaesthetist and can happen in spite of properly calculated risk. Anaesthetic deaths are very rare and only one in ten thousand person die totally as a result of anaesthesias. Table 10.1 narrates the exact incidence of anaesthetic deaths. Anaesthetist should ensure the safety of the patient. However, in a case of the death under anaesthesia it is better to report the matter to police for conducting inquest and postmortem examination. At autopsy, known sites of sudden catastrophe should be carefully investigated for, such as coronary disease, pulmonary embolism and inhalation of vomit or blood. All too often the tragedy may be due to a combination of errors in varying proportions rather than one particular mistake. However, any such death believed to be caused, or contributed to, by any of these procedures may be adequately investigated both from the point of view of the satisfaction of the relations of the deceased and instituting future safety/ preventive measures.

ANAESTHETIC DEATHS Anaesthetic deaths are of two types: 1. Deaths due to anaesthesia and anaesthetic agents. 2. Deaths due to factors other than anaesthesia. Deaths Due to Anaesthesia and Anaesthetic Agents Deaths due to anaesthesia and anaesthetic agents could be due to three reasons: 1. Anaesthetic agents 2. Anaesthetists 3. Functional problems.

Anaesthetic Agents Anaesthetic agents may sometimes result in hypersensitivity reaction resulting in death of the patient. Certain anesthetics can directly act with a consequence of cardiac arrhythmia and cardiac arrest. The use of certain drugs, which can create myoneural blockage, may give rise to death due to respiratory inadequacy/ failure. There is evidence that halothane can cause liver necrosis resulting in malignant hyper pyrexia which is characterised by abrupt rise to dangerous temperature (about 110°F) and also may be associated with tachycardia, hyperpnoea, cyanosis and stiffening of the muscles and may ultimately lead to death. This condition is believed to be genetically determined and likely to occur in families having evidence of subclinical myopathy and an exceedingly high level of serum creatinine phosphokinase (Table 10.2).

Chapter 10: Medical and Legal Aspects of Anaesthetic and Operative Deaths

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Medical and Legal Aspects of Anaesthetic and Operative Deaths

Table 10.1: Incidence of anaesthetic deaths6 Reported causes Disease for which the operation was conducted Shock and inevitable risks of the operation Risks and complications of anaesthesia Over dosage, maladministration or bad choice of the anaesthetic agent

Incidence(%) 56 30 08 06

Table 10.2: Causes of death due to anaesthetic agents • • • • •

Hypersensitivity Cardiac arrhythmia Cardiac arrest Respiratory inadequacy Malignant hyperpyrexia

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Anaesthetists Anaesthetists who are using improper technique, improper equipments or one who has no familiarity with the equipment, having no adequate experience, or unable to adopt precautions when indicated, or careless in the methods, etc. can always land up with anaesthetic deaths. Hypoxia, improper depth of anaesthesia, vagal inhibition, etc. constitutes usual causes of anaesthetic deaths. Basically, all these causes are secondary to obstruction of the airways, or a faulty gas connection, etc. due to mechanical problems consequent to several causal agents (Table 10.3). However, it is reported that of all these causal agents, human error alone was responsible for 82 per cent of the anaesthetic deaths, while equipment failure occurred in another 14 per cent of cases and all other factors caused death in rest of the 04 per cent patients. Functional Problems The common problems relate to vagal inhibition, obstruction of the glottis due to spasm, tube, or vomit; cardiac arrhythmia; and hypotension. The unconscious patient poses a special problem in regard to anesthesia, as he is unable to take corrective reflex action against inhalation of foreign material. Table 10.4, enumerates the functional causes of anaesthetic death. Deaths Due to Factors other than Anaesthesia Deaths due to factors other than anaesthesia are enumerated and discussed as follows: • Disease or injury for which the operation or anaesthesia is being given. Here the anaesthesia or surgery is playing no role in causing the death of the patient. Rather it is the disease or the injury in itself has resulted in death. The surgery is usually accepted as a challenge with the remote hope to save the victim’s life. • Disease or abnormality other than that for which the surgical operation is undertaken. • Surgical mishaps and/or postoperative events. Table 10.3: Causal agents and cause of death Human error (82%) • Carelessness • In-experience • Unfamiliarity with equipment • Inability to adopt precautions • Mishaps due to intubation/bronchoscopy Equipment failure (14%) • Kinked pipes • Cross tubes • Over dosage • Malfunction of the apparatus • Explosion Other factors (04%) • Inadequate communication between staff • Haste • Distraction

Table 10.4: Functional problems of anaesthetic deaths • • • • •

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Vagal inhibition Obstruction of the glottis due to spasm, tube, or vomit Cardiac arrhythmia Hypotension Unconscious patient

• Physical status of the patient, e.g. old age, diabetes, high blood pressure, etc. • Surgical mishaps such as unintentional accidental tearing or cutting of a major blood vessel during surgery resulting in death and therefore such deaths are detectable only at autopsy. • Postoperative consequences such as death due to phlebothrombosis, pulmonary embolism, aspiration of the vomit, etc. These cannot be considered as part of anaesthetic procedure or that of surgery. Undoubtedly an important postoperative precaution with an accomplished nursing care maintaining the safe position of the patient can certainly prevent this. • Unforeseeable problems—patients with haemoglobinopathies, especially sickle cell anaemia, are unduly susceptible to low oxygen tension in blood and this may pose a hazard to the unawarded surgeon or anaesthetist. Coronary thrombosis may supervene in a patient operated upon for injuries. Transfusion hepatitis is not unknown. AIDS infection through transfusion is another possibility. MODE AND CAUSE OF DEATH Two important modes of death are cardiac arrest and respiratory failure. Cardiac Arrest Cardiac arrest is the most common mode of death. Basically, this is due to either oxygen deprivation or carbon dioxide accumulation as a result of failure of technique or fault in technique. Most cardiac arrests occur under relative light anaesthesia and therefore tend to occur at either the start of the operation or conclusion of the surgical procedure. Cardiac arrest, thus supervene in three ways: 1. Asphyxia of myocardium (Flow chart 10.1) 2. Overdosing of anaesthetic agents 3. Reflex vagal stimulation.

Asphyxia of Myocardium Hypovolaemia and some diseases of the cardiovascular system carry an enhanced risk. Presented below are the various events of effects of asphyxia on myocardium resulting in cardiac arrest. Overdose of Anaesthetic Agents Over dosage during anaesthesia, act in two different ways: Firstly, there may be an inadvertently high concentration of the agent in the bloodstream. This will produce marked vasodilatation, causing a fall in blood pressure while the heart is receiving a relatively high concentration of the agent via the coronary vessels. The heart may become sufficiently poisoned so that it is unable to produce a compensatory rise in output and will fail ultimately. Secondly, cardiac arrest may be caused by prolonged administration of an anaesthetic in concentrations sufficiently high to gradually poison the myocardium. Reflex Vagal Stimutation Hypoxia, sudden asystole can stimulate vagus nerve resulting in slowing of the heart. Vagal stimulation per se is unlikely to occur spontaneously when the circulation is hypoxic, but respiratory irritation causing bronchial spasm results in vagal over activity and hypoxia. It has been postulated that patients suffering from a natural over activity of the parasympathetic system are more likely to have such a reflex arrest.

Respiratory Failure Death due to respiratory failure may result during and/ or after the anaesthesia and surgical procedure. Various potential causes are enumerated as below: • Overdose of premedication drugs such as barbiturates, tranquilizers, morphine, pethidine, etc can depress respiration, leading to hypoventilation and anoxaemia. • Overdose of anaesthetic drugs/administering deep anaesthesia with consequence of the respiratory muscles paralysis. • Administration of opiates during postoperative period for the relief of pain may depress the cough reflex causing retention of the sputum leading to secondary infection of lung. • Obstruction of larynx or trachea by laryngospasm and/or bronchospasm, secretions from the throat, blood, swabs, dentures or gastric contents may lead to hypoxia. • Hypoventilation and hypoxia due to hyperventilation by the anaesthetic agents may cause depletion of carbon dioxide, during the recovery-period. INVESTIGATION AND EXAMINATION OF A CASE OF AN ANAESTHETIC DEATH In investigating a case of an anaesthetic death, a forensic pathologist should take several factors into consideration. A thorough review of hospital chart and discussions with the surgical and anaesthetic team is essential collecting relevant history pertaining to victim about how was his period prior to hospitalisation; during stay in the hospital, at the phase of preparation of anaesthesia, and for how long the anaesthesia affect lasted. Enumerated below are some of the important factors to be evaluated individually:

• Condition for which surgery was performed: Look for highrisk surgical conditions, e.g. resection of an aortic aneurysmal repair. • Preexisting other conditions: Some contraindications to operative procedures are not easy to identify. Even if these conditions are identified, their seriousness may not be appreciated. For example, coronary artery disease may prove fatal due to increased anoxia by the anaesthetic agents. • Anaesthetic agents: Inadvertent mixing of the anaesthetic gases may cause death. It is important to get information on anaesthetic agents used, its quantity and method of administration. Note also the duration of time for which the patient remained under anaesthesia. • Burn or explosion: Deaths from anaesthetic explosions occur rarely. • Shock and haemorrhage: Haemorrhage and shock should be evaluated with other findings of the case. • Blood transfusion: Blood transfusion reactions and incompatibilities should be also looked for. • Resuscitative measures: The measures adopted should be noted. • Equipment: With appropriate qualified individuals, all the equipments including the valves and containers should be checked to assure the correct mixing of per centages. Devises attached to and inserted into the body should be examined. AUTOPSY EXAMINATION IN A CASE OF AN ANAESTHETIC DEATH This includes three things: Precautions, Autopsy procedures and Chemical analysis.

Chapter 10: Medical and Legal Aspects of Anaesthetic and Operative Deaths

Flow chart 10.1: Presenting cardiac arrest due to asphyxia of myocardium

Precautions In order to avoid criticisms it is better take all necessary cautions preventing all harms or dangers. • Surgical mistakes are gross and anatomical and hence are observable at the postmortem. • Anaesthetic mistakes being physiological are no longer appreciable after death except where overdose with specific drug is involved. • Look for or exclude some of the natural disease or mechanical obstruction. • Autopsy must be preferably done by a forensic expert and it must, however, be remembered that the findings of the autopsy surgeon alone will not be sufficient to explain death. • It is imperative to hold a discussion across the autopsy table involving forensic expert/autopsy surgeon, anaesthetist and the surgeon concerned. • It is often stated that deaths under anaesthesia were more often the fault of the anaesthetist than the anaesthetic. Autopsy Procedure Autopsy in a case of an anaesthetic death must be performed methodically adopting all the standard procedures. However, care is taken to undertake following unfailingly: • Note the odour: With inhalant anaesthetics, specific odour of anaesthetic agent may be detected at autopsy. • Body cavities: Examine in situ all the cavities. Measure the contents or fluids if any and preserve for analysis. • Site of surgical intervention: Examine the site of surgical intervention in situ and describe in detail. • Surgical sutures and organs: Dissect all organs and inspect every surgical suture. 61

Part II: Medical Jurisprudence

• Signs of prolonged anaesthesia: Dependent parts of the viscera are usually seen engorged in cases of prolonged anaesthesia. • Effect of anaesthetics: Chloroform and halothane are hepatotoxic and chloroform may rarely produce ventricular fibrillation. Halogenated hydrocarbons like cyclopropane, trichloroethylene and halothane cause cardiac irritability. They sensitize myocardium to the action of adrenaline. • Evidence of pulmonary embolism and asphyxia: Look for presence of pulmonary fat or air embolism or evidence of asphyxia due to aspiration of regurgitated material which are diagnostic about cause of death. • Internal findings of haemorrhage, peritonitis and retained swabs and instruments, or evidence of hypersensitivity reaction are obvious. • Evidence unnoticed: Evidence of vagal inhibition, fall in blood pressure, cardiac arrhythmias, coronaries and laryngeal spasms, etc. could not be detected during an autopsy. • Histopathological examinations: Collect the sample from all viscera for histopathological study. – Specimens should be taken particularly to exclude any cardiovascular disorder including occult conditions like myocarditis as well as relavent specimens for assessing the severity of disease for which the operation was carried out. – Histological examination of the brain is imperative which is primarily intended to demonstrate the effects of hypoxia, particularly in the region of Sommer’s area of the hippocampal gyrus and the cerebellum, where changes are expected even if the victim suffers hypoxia for a short period. – Morphological changes5 in the brains of victims who suffered hypoxia for a short period but survived for long periods after anaesthesia included-diffuse, severe leucoencephalopathy of cerebral hemispheres with sparing of the immediate subcortical connecting fibres. Demyelination and obliteration of axons was also observed and at times, infarction of the basal ganglia. Damage appeared limited to the white matter, which is explained on the basis of greater glycolysis in the white matter during hypoxia as compared with the grey matter. Chemical Analysis • A lung is removed and collected by clamping the main bronchus and retained in a nylon bag and sealed so that the headspace gas can be analyzed. • Collect the alveolar air with a syringe by pulmonary puncture before opening the chest. • Prior to autopsy to avoid loss of gases due to exposure of the tissues to the air, it may be necessary to obtain samples of every viscera by the biopsy techniques and frozen immediately. • At autopsy some portion of fat from the mesentery, skeletal muscle tissue, brain, liver, half of each kidney are retained. • Blood should be collected under liquid paraffin. • Urine should also be collected, if available. All these specimens should be collected in containers with as little headspace as possible, sealed and immediately refrigerated or frozen.

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Bacteriological Examination Adequate blood, urine and other body fluids may have to be collected.

Hazards of Transfusion of Blood and Body Fluids Blood and various body fluids should be preserved for analysis. Extraneous Specimens Like residual solutions, medication containers, samples of gases used for the anaesthesia and samples of the operating room air may have to be collected in occasional cases. COMMON MISHAPS IN ANAESTHETIC PRACTICE The most common errors leading to anaesthetic complications are human error. It may be due to lack of vigilance due to haste or fatigue. Inexperience or inadequate knowledge may also contribute to this. Some of the common mishaps encountered are enumerated in Table 10.5. Mistaken Identity It is quite common that due to mistaken identity, a wrong procedure may be initiated on any individual. Mistaken identity can result in mismatched transfusion leading to serious complications. In India, the common practice is to place a leucoplast sticker containing name, age, sex and ward of the patient on the arm or sternum of the patient. This sticker may be accidentally washed or it may come out due to sweat of the patient. In Western countries, special identification bands are available which cannot be removed easily and are washproof. Efforts made in making such identification bands available in the Indian market and it is advisable to use them whenever available. It is advised that before commencing any procedure, identity of the patient may be confirmed again by asking the patient or his relatives. Incorrect Positioning of the Patient Incorrect positioning of the patient on the table can create complication like nerve palsy or problems in cardiovascular or respiratory management. It is true that the surgeon decides positioning of the patient, but anaesthetist should take precautions and caution the surgeon when required. The following precautions are recommended: • Eyes should be shut and well protected. Pressure on eyeballs can cause retinal vein thrombosis and blindness. • Elbows should be protected as allowing them to lie unprotected against table can cause ulnar nerve palsy. • Abduction of arms should not be done beyond 90o. Excess abduction can result in traction injury of bronchial plexus. • Sciatic nerve injury can occur during movement to lithotomy position, if both knees and hips are not flexed simultaneously. • If patient is in prone position, there may be pressure on abdomen, which can cause obstruction of venous return, and there may be restriction in the movement of diaphragm. • If there is sudden change of movement, it can cause venous pooling and interference with cardiac output. It may also cause sudden extubation. Table 10.5: Common mishaps in anaesthetic practice • • • • • • • • • •

Mistaken identity Incorrect positioning of the patient Fault in the anaesthetic machine Failure of suction apparatus Perforation of airway Electrocution or burns Fault with intravenous equipment, Mishaps with drugs Monitoring of vital signs Human error

Faults in the Anaesthetic Machine There may be faulty gas supply due to incorrect connection or leaks. It may be due to cylinders being empty or proper pipeline supply is not there. Flow meters may have leaks or incorrect settings. In vaporisers a wring agent may be there or there may be leaks or errors in calibration. • Faulty anaesthetic circuit: The anaesthetic circuit may be faulty due to disconnection or leaks or improper setting of APL valve and pressure limiting device. • Fault in ventilator: It may be due to disconnection or leak or electric current failure. • Laryngoscope may cause injuries to lips and teeth. There may be failure in light supply. • Endotracheal tube may be leaking, cuff may be ruptured, obstruction may be present due to kinking. There may be bronchial or oesophageal intubations. Failure of Suction Apparatus This is grave especially in emergency cases. Perforation of Airway Malleable stylet may cause such perforations. Electrocution or Burns Electrocution can occur because of leakage in electric circuit commonly with use of cautery. Burns are also reported because of leakage of current. Fault with Intravenous Equipment Catheters may be misplaced. Sometimes, air embolism or embolisation of catheter fragments is reported. Mishaps with Drugs Improper labeling can lead to wring drug being administered. If by mistake expired drug is used, it can cause overdose or underdose. Monitoring of Vital Signs Every anaesthetic procedure requires close monitoring of vital signs at regular intervals. It is one of the most important areas of anaesthetic care. Patient’s condition may worsen if there is a failure to recognize signs of impending danger. Human Error Three types of human errors are described: a. Errors due to failure of monitoring and vigilence. b. Technical errors due to inefficiency in skills required or due to poor design of the equipments and apparatuses. c. Judgemental errors due to bad decisions by improper/poor training in skills of decision making. PREVENTING ANAESTHETIC MISHAPS Proper Maintenance of Equipments All anaesthetic instruments should be regularly checked for leakage, proper wiring and proper functioning. The following items should be checked before operation: • Suction apparatus for tubing, catheter. • Endotracheal equipment like laryngoscope end tracheal tube. • Intravenous drugs for correct labeling date of expiry. • Ventilators.

• Proper vigilance: It is the cornerstone of anaesthetic practice. Vital signs should be recorded every five minutes. Continuous monitoring of oxygenation and cardiac output should be done. HANDLING CASE OF ANAESTHETIC MISHAP • Never panic. • The situation should be corrected immediately. • Call for help from other areas or request surgical team to help you out. – Document all the procedures done in finest detail as this is the only defense a doctor can have later on that he has done judiciously what was the need of the time. – In postoperative period, discuss with patient the circumstances of the case. – If patient is dead, talk to the relatives in detail and explain what happened. – Not talking to patient/relatives can lead to unnecessary litigation. – If you think litigation may follow, inform insurance company from where you have taken insurance policy. MEDICOLEGAL CONSIDERATIONS • Code of Criminal Procedure, 1973, Sec. 39—All deaths occurring during the course of anaesthesia and surgery or within a reasonable period thereafter should be reported to the police.7 • These deaths, all too often the tragedy may be due to a combination of errors rather than one particular mistake or sometimes due to some significant pre-existing disease or some co-existent condition. • Tendency on the part of the relatives of the deceased to impute negligence on the part of the anaesthetist and/or the surgeon merely because of the fact that the death was closely associated with the anaesthesia and surgical intervention. • Apportioning relative contribution between the anaesthetist and the surgeon is extremely difficult and both are required to exercise due care and skill. Each one is responsible for negligent acts of oneself and not of the other. • As the surgeon possesses absolute control over the staff that assists him in the operation he will be liable for the negligent acts of his assistants. However, the surgeon, has no absolute control over the activities of the anaesthetist and the connected staff. • If the postmortem examination yields negative results and the autopsy-surgeon may not be in a position to express conclusive opinion and the cause of death remains nothing more than conjectural one. • The role of autopsy surgeon may remain limited, largely to the detection of some natural disease, overt signs of damage by the anaesthetic procedure or errors in the surgical procedures.

Chapter 10: Medical and Legal Aspects of Anaesthetic and Operative Deaths

• Protect the patient from hazards of electrocution by avoiding contact of the patient with the metal parts of the operating table.

DEATH ON OPERATION TABLE It has been estimated that expectancy of death from all causes during operation and anaesthesia is 1 in 1000.8 The reasons contributing to death on operation table are mainly due to anaesthesia and surgery. It may be possible that person may die from the injury or disease for which operation is carried out; for example, in repair of ruptured liver or ruptured lung, person may die within the stage of organ being repaired. Death may also due to a disease other than that for which operation 63

Part II: Medical Jurisprudence

is being carried out but was diagnosed or not diagnosed before operation. It is possible that a person may die of pre-existing disease like rheumatic heart disease, rupture of aneurysm or myocardial infarction during surgery. Major surgical complications like shock can also cause death on operation table. No surgery is without a risk is a famous saying and is true. But maximum number of lawsuits is against surgeons only. While during surgery, he is captain of the team and, by the doctrine of respondent superior, is responsible for any mistakes of any member of the team. Negligence attributed during surgical practice can be divided into the following: • Negligence due to anaesthesia and surgeon has no role to play. • Negligence primarily by surgeon alone. • Negligence by operating assistants. • Corporate negligence during surgery or in postoperative phase. Negligence primarily due to anaesthesia and surgeon has no role to play (Discussed above). Negligence Primarily by Surgeon Alone Described as Acts of Omission and Acts of Commission.

Acts of Omission • Failure to assess surgical condition properly. • Failure to decide whether surgery is required or not. • Failure to decide correct surgical approach. • Delay in planning operation leading to complications. • Failure to use diagnostic techniques properly. • Failure to take informed consent. • Failure to carry out operation properly. • Failure to provide good postoperative care. • Failure to provide instructions and precautions to patient. • Failure in follow-up of patient regularly. Acts of Commission • Operation more extensively carried out than consented by the patient. • Operation conducted on wrong patient or on wrong side. • Leaving swabs or instruments in the body after surgery. • Use of unsterile instruments or operation theatre.

64

• Unnecessary cutting of body tissues. • Applying plaster casts too tight or too light for a longer time than required. • Committing major blunder like cutting of big vessel or respiratory passage inadvertently. Negligence by Operating Assistants Surgeon is fully responsible for the mistakes of his assistants like nurses and other paramedical staff during operation, although they also have to share responsibility for the mistakes they have committed. Corporate Negligence during Surgery or in Postoperative Phase Due to faulty instruments, inadequate facilities in operation theatre, etc. patient may receive injuries during operation or operative care. For example, • Leaking cautery during operation may electrocute patient. • Patient may fall off from the operating table due to a defective table. • Patient may get injured while being shifted from one place to the other. REFERENCES 1. Knight B. Legal Aspects of Medical Practice, 5th edn. Churchill Livingstone, 1997. 2. Knight B. Simpson’s Forensic Medicine Arnold: London, 1997. 3. Singhal SK. The Doctor and Law, The National Book Depot, Mumbai, 1999. 4. Arora M (Ed). Kausal AK’s Medical Negligence and Legal Remedies with Special Reference to Consumer Protection Law. Universal Book Traders, 1995. 5. Plum F, Posner JB. Diagnosis of Stupor and Coma, 3rd edn. Philadelphia, F Davis and Co. 1984; 218-19. 6. Cooper JB, Newbowenks, Kitz RJ. An analysis of major errors and equipment failures in anaesthesia management: Considerations for prevention and detection. Anaesthesiology 1984;60:34-42. 7. Rathanlal, Code of Criminal Procedure, 1973, Sec. 39. 8. Lahey and Rezicka, Death on Operation Table. J Surg Gynec Obste 1990.

11

Forensic Identity

INTRODUCTION Identification of a person is vital among the living and the dead. In civil and criminal courts, results of trials often depend upon establishing proper identity. In deaths due to violence, law needs to establish the exact identity of the deceased prior to final verdict. Identity happens to be the part and parcel of corpus delicti or body of crime. Identification of the Living This is usually done by the police and is essential in both civil as well as criminal cases. Identification of the living becomes necessary when through debility, illness, mental confusion or unsoundness, immaturity, infancy, unconsciousness or true amnesia, evidence of identity is not forthcoming from a person who has no relatives or friends immediately available and who carries no documentary evidence of identity. Such cases are sometimes seen in vagrants, residents of lodging houses or hotels, victims of accidents, fires and mass tragedies or disasters, such as rail, air crash or ship wreck. Other circumstances where a living person may require establishing of identity are—absconded soldier, a criminal accused of assault, rape, murder, etc. cases of swapping of neonates in a maternity home, cases of false impersonation for insurance claims, inheritance of property, passport, school admissions, disputed paternity, dubious sex identity, etc. Identification of the Dead In a dead body, identity is often of paramount importance in criminal or suspicious death investigation, as in cases of victims of homicides, where in the body may be mutilated. Identification of the victim is hence a major step towards identification of the culprit responsible for the death. Decomposition and skeletonisation, may render identity even more difficult. The other important situations where in identity of dead body is vital, are among the victims of mass disasters in natural calamities such as an earthquake or a terrorist bomb blast or conflagration of a crowded building. Thus, detailed examination of the dead for evidence of identity becomes a specialised task for the forensic pathologist and other forensic experts.

Pedigree Pedigree is a method of establishing identity of the criminal involved in a crime in a police station. It include personal details

Chapter 11: Forensic Identity

Part III: Forensic Pathology

such as name, his/her alias, address residence, colour of the skin, age, height, build, colour of the hairs, colour of the eyes, complexion, presence or absence of moustache, birth place, occupation, etc. This when combined with photographs and finger prints serves in establishing the identity of a criminal. DEFINITION Identity is defined as the recognition of the individuality of a person, live or dead. CLASSIFICATION For all purposes, personal identity is classified into two types: complete identity and partial identity. In addition, legal identity is described herewith. Complete or Absolute Identity Here the exact fixation of individuality of the person, alive or dead, is possible. Partial or Incomplete Identity Here the exact fixation of individuality is not possible, but identity to the extent of certain facts about the person is only possible, i.e. age of the person, sex of the person, race of the deceased, occupation of the person, etc. is possibly established. Legal Identity Here the exact fixation of the individuality is impossible, because he or she has been unknown to the people around. Such cases are coded by a number or alphabetical letter or such other methods by the police, constituting legal identity. Examples: A dead body, recovered by the police in the central part of the city, being unknown is labeled and registered as body No: A. Another dead body recovered in some other part of same city, if again unknown, for registering the case may be labeled as body No: B, etc. Discussed below are various aspects of personal identity with respect to its applied medicolegal context briefly. CORPUS DELICTI (BODY OF OFFENCE, ESSENCE OF CRIME) In a trial of homicide, it is necessary to establish identity of the person who is dead.1 Corpus delicti means facts of any predefined criminal offence. Thus in a case of homicide, corpus delicti includes not only the dead body but also all other factors 65

Part III: Forensic Pathology

which are conclusive of death by foul play such as a bullet found at the crime scene or in the dead body, a piece of broken knife at the crime scene, a drawing/photograph of the deceased showing fatal injury, etc. all may be included. The main fact of corpus delicti is the establishment of identity of the dead body, infliction of violence in a particular way, at a particular time and place, by the person or people charged with the crime and none other. The case against the accused cannot be established unless there is convincing proof of these points. If the identity of the victim is not known, it becomes difficult for the police to solve the crime. The identification of a dead body and proof of corpus delicti is essential prior to passing sentence in murder trials. However, there are cases reported where in the death sentence is passed even when the dead body was not found or identified. Dermatoglyphics or the ridge patterns of skin of the palms and soles are highly individualistic, providing positive identification of mutilated or putrefied remains. The advent of DNA finger printing helps conclusive and complete identity even with a few drops of blood or body fluids, or a bit of tissue, hair, bone, teeth, etc. This is possible even when there is no antemortem record of the dead, since the DNA can be compared with that of the close/blood relatives of the deceased.2,3,23,24,29 FACTORS ESTABLISHING PERSONAL IDENTITY Identification of a person live or dead can be established in general by certain factors,1-6 which are illustrated in Figure 11.1 and enumerated below: 1. Age 2. Sex

3. Other factors: • Race and religion/ communal characters • Stature and general development • Hairs • Complexion • Features • Deformities • Tattoo marks • Moles • Scars • Occupational stigmata • Dactylography • Poroscopy • Footprint • Lip prints • Palato prints • Ear prints • Anthropometry • Superimposition • Personal belongings: – Clothes, – Pocket contents, – Key bunch – Wrist watch – Jewellery, etc. • DNA finger printing • Brain finger prints • Trace evidence factors Each of these factors are discussed ahead.

Fig. 11.1: Factors useful in establishing human identity

66

Age of a person is an essential factor in establishing the personal identity, and it can be determined by following factors: • Morphological characteristics • Dentition (Teeth) • Ossification of bones • Miscellaneous data. These factors can establish the age with a reasonable accuracy almost up to 25 years3,5 and beyond 25 years, these factors are unreliable.1-6 However, for the sake of convenience estimation of age is practically considered in three phases of life, namely:

• Intrauterine life (IUL) • From birth to 25 years age • Above 25 years. Intrauterine Life (IUL) The age of a foetus during IUL can be assessed by studying the developmental morphology, appearance of ossification centres in skeletal bones, and also germination of teeth. A glance at the external and internal foetal autopsy findings emphasize the significance about developmental morphological factors helpful in establishing age during IUL (Tables 11.1 and 11.2). Another method of establishing age during the IUL of the foetus is by Haase’s rule.

Chapter 11: Forensic Identity

AGE AND IDENTITY

Table 11.1: External and internal autopsy findings of foetal developmental changes Features

Observations Viable foetus (at 7 months)

Full term foetus (End of 10 lunar months)

Length

35-38 cm

50 – 53 cm

Weight

1060 gm

2.5-5 kg (Average – 3.4 kg)

Head:Circumference

—

33 – 36 cm Head is 1/4th of its whole body length

Fontanels

—

Six (total) and they are: Bregma -(Anterior fontanel) – one at the junction of sagittal with coronal suture (size: 4 × 2.5 cm) Lambda (Posterior fontanel) – one at the junction of sagittal and lambdoid suture. Lateral - two at the sphenoparietal junction on either side Mastoid (posterolateral fontanels) –two at mastoidoccipital junctions on either side.

Eye brows/lashes

Formed

I. EXTERNAL

Eye lids

Open

Pupillary membrane

Absent

Face

Wrinkled

Not wrinkled

Nose & Ears

Cartilages not formed

Cartilages formed

Limbs, hands, feet, fingers and toes

Formed

Nails

Present

Project beyond the tip of fingers of the hands Project up to the tip in toes of the feet

Umbilicus

Cord present

Midway between pubis and xiphoid cartilage

Placenta

Weight: 350-400 gm

22 cm in diameter, 1.5 cm thick at the centre and weight – 500 gm

Genitals

Formed

– Testes are in the scrotum – Vulva is closed and labia minora are covered by fully developed labia majora

Hairs a. Body b. Scalp

Lanugo on whole body Present

Lanugo absent, except on the shoulders Dark and 3-5 cm long

Skin

Dusky red, and thick

Pale and covered with vernix caseosa

Ossification centre appears in

– Talus – Sternum (2nd piece)

– Lower end of femur – Cuboid and – Upper end of tibia

Brain: Convolutions Grey matter

– Formed – Not formed

– Well formed – Begins to form

Intestines, gallbladder - bile

Present

Meconium

Present in the colon

Caecum

In right iliac fossa

Testis

At external inguinal ring

II. INTERNAL

Dark brownish and present in the rectum Present in the scrotum

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Part III: Forensic Pathology

Table 11.2: Intrauterine age-related changes in the foetus At the end of IUL (Month)

Length and weight (cm/g)

Sex

Skin

Hair

Eyes

Nails

Testes

Meconium

Others

1.

1 cm 2.5 g

—

—

—

Two dark spots

—

—

—

—

2.

4 cm 10 g

—

—

—

—

—

—

—

—

3.

9 cm 30 g

—

—

—

—

—

—

—

—

4.

16 cm 120 g

Recognized

—

Lanugo on body

—

—

—

In duodenum

Brain convolutions begin

5.

25 cm 400 g

—

Vernix caseosa

Scalp appeared Light

—

Distinct Soft

—

Beginning in large Intestine

Gallbladder contains bile

6.

30 cm 700 g

Well differentiated

Red and wrinkled, subcutaneous fat begins to deposit

—

Eyebrows and eyelashes appear

—

Close to the kidneys, on psoas muscle

—

—

7.

35 cm 900-1200 g

—

Dusky-red, thick, fibrous

Scalp 1 cm long

Eyelids open, pupillary membrane disappear

Thick

At external inguinal ring

Whole of large intestine

Caecum in right iliac fossa

8.

40 cm 1.5-2 kg

—

Not wrinkled

Scalp Thick 1.5 cm

—

Reach tips of fingers

Left testes in the scrotum

—

Placenta weighs 500 gm

9.

45 cm 2.5–3 kg

—

—

Scalp Dark and 2-4 cm long

—

—

Both in scrotal sacs, which are wrinkled

At the end of large intestine

Posterior Fontanels closed, Ossification centre for femur (lower end), Cuboids, Capitates-appeared

Haase’s rule: This enables the estimation of the age of the foetus in lunar months from the crown-heel length (in cm) of the foetus. Accordingly, until the foetal length is 25 cm, square root of the length determines the age of the foetus and when the length is >25 cm, age is derived by dividing the length by 5. From Birth to 25 Years Age

Morphological Characteristics In both living and dead, age of the person can be determined by the height and weight referring to standard height and weight for men and women and also by the secondary sexual characteristics (Table 11.3). Dentition (Teeth) The science dealing with establishing identity by teeth is popularly known as forensic odontology or forensic dentistry, which is gaining more popularity these days on account of frequent mass disasters. Eruption of different teeth has a definite pattern and it occurs at different ages. Human dentitions are of two types:5,10-12 (i) deciduous dentition, and (ii) permanent dentition. Deciduous dentition (Temporary/milk teeth): These are the teeth present during early part of life, i.e. in childhood and they are 68

totally 20 in number and begin to erupt at sixth month after birth and begin to shed off by sixth year (Fig. 11.2). The tooth distribution in each jaw is as follows: • 4 incisors • 2 canines • 4 molars Thus, each jaw has 10 teeth. Permanent dentition: These are the teeth present during life, which begin to erupt from sixth year of age and remain throughout the life. They are totally 32 in number (Figs 11.3A and B). The tooth distribution in each jaw is as follows: • 4 incisors • 2 canines • 4 premolars • 6 molars. Thus, each jaw has 16 teeth. Among these 4 incisors and 2 canines and 4 premolars are called as successional teeth, which erupt in the place of predecessor deciduous teeth, with 4 premolars (1st premolar and 2nd premolar) erupt in place of 4 temporary molars. The remaining 6 permanent molars (1st, 2nd and 3rd molar teeth) erupt independently without any predecessor teeth.25 These 6 molars are called superadded teeth

Height

Men (Weight)

Women (Weight)

Metres

0’ 0”

kg

lb.

kg

1.523 1.5484 1.5738 1.5992 1.6246 1.650 1.6754 1.7008 1.7262 1.7516 1.7770 1.802 1.8278 1.8532 1.8786 1.9040

5’ 0” 5’ 1” 5’ 2” 5’ 3” 5’ 4” 5’ 5” 5’ 6” 5’ 7” 5’ 8” 5’ 9” 5’10” 5’11” 6’ 0” 6’ 1” 6’ 2” 6’ 3”

…. …. 56.3 – 60.3 57.6 – 61.7 58.9 – 63.5 60.8 – 65.3 62.2 – 66.7 64.0 – 68.5 65.8 – 70.8 67.6 – 72.6 69.4 – 74.4 71.2 – 76.2 73.0 – 78.5 75.3 – 80.7 77.6 – 83.5 79.8 – 85.9

…. …. 124 – 133 127 – 136 130 – 140 134 – 144 137 – 147 141 – 151 145 – 156 149 – 160 153 – 163 157 – 168 161 – 173 166 – 178 171 – 184 176 – 189

50.8 –54.4 51.7 – 55.3 53.1 – 56.7 54.4 – 58.1 56.3 – 59.9 57.6 – 61.2 58.9 – 63.5 60.8 – 65.3 62.2 – 66.7 64.0 – 68.5 65.8 – 70.3 67.1 – 71.7 68.5 – 73.9 ….. …. ….

lb. 112 – 120 114 – 126 117 – 125 120 – 128 124 – 132 127 – 135 130 – 140 134 – 144 137 – 147 141 – 151 145 – 155 148 – 158 151 – 163 ….. ….. …..

Chapter 11: Forensic Identity

Table 11.3: Age by height and weight data (Standard heights and weights for men and women— by Life Insurance Corporation, India)

Note: Maximum weight that one may reach: Up to the age of 30 years, 10% above standard, between 30 and 35 years, standard is optimum weight, above 35 years, 10% below standard.

Fig. 11.3A: Superadded and successional dentition

Fig. 11.2: Deciduous dentition

(Fig. 11.3A). Table 11.4 enumerates the different ages at which the temporary and permanent teeth erupt, and Table 11.5 gives the important differences between both dentitions. Figure 11.3B, illustrates teeth eruption in a skull of 12 years old age.

Other Factors about Teeth in Determining Age 1. Degree and extent of calcification of roots of teeth ascertained by X-ray examination. 2. Attrition of teeth, i.e. wearing off the teeth on the grinding surface begins in the molars after middle age (Fig. 11.3C). 3. Old age — all teeth are lost and individual becomes edentulous.

Fig. 11.3B: Showing tooth development and eruption patterns: The left side of the maxilla and jaw bone has been cut opened to show adult teeth descending while the deciduous teeth are still in place. The specimen shows two of the teeth are only visible after part of the mandibular cortical bone has been removed. All available evidence suggests an age of 11 to 13 years

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Part III: Forensic Pathology

Table 11.4: Temporary and permanent dentition eruption ages Teeth

Lower/ Upper

Temporary

Permanent

Central incisor

Lower Upper Lower Upper — — — — — —

06-08 months 07-09 months 07-09 months 10-12 months 18-20 months Absent Absent 12-14 months 20-30 months Absent

07-08 07-09 07-09 08-09 11-12 09-11 10-12 06-07 12-14 17-25

Lateral incisor Canine First premolar Second premolar First molar Second molar Third molar

years years years years years years years years years years

Table 11.5: Differences between temporary and permanent teeth Characteristics

Deciduous teeth

Permanent teeth

Size Colour Constriction at the crown-root junction Edge Cusp

Smaller Porcelain white

Larger Ivory white

More prominent

Less prominent

Sharp Few and small

Mammelons/lobes (Serrated) More in Number and well developed

}

Fig. 11.3C: Normal teeth with prominent cusps (left side), while total worn out teeth (attrition) on right side

Gustafson’s Method/formula1,4,5,11-15 Gustafson described a method wherein various criteria of normal physiological changes in a tooth other than dental eruption order are considered in determining the age of a person. Figure 11.4A, Tables 11.6 and 11.7 describe these criteria briefly. The method is useful in determining the age of the victim, when teeth are the only trace evidences collected as in cases of victims of bomb blast or air crash disasters. If the eruption order of teeth could help determine the age up to 25 years, Gustafson’s method is helpful in determining the ages beyond 25 years. Following examination of the tooth based on the aforementioned criteria,13 the total score obtained is applied to a regression formula and the age is estimated as below: Estimated age (years) = 11.43 + 4.56 × (Total score)

Other Approved Methods of Establishing Age by Teeth16-18 • Age by cross striations of incremental lines in the tooth enamel: The age of a person can be determined by counting the number of lines from the neonatal line onwards (Figs 11.4B to D). Accuracy of the method is poor beyond infancy with an error possibility of ±20 days.16 70

• Age by cemental annulations: The age is determined by this method at a high accuracy.17 These are alternating light and dark lines visible under light microscopy of ground section of human tooth root cementum, are believed to be incremental lines and repeat an annual rhythm. Figure 11.4E illustrates transeverse section of human premolar with cemented annulations. • Age by racimisation ratio (D/L ratio): Here accurate age (± 4 years) estimation is described by the dentin of the teeth using the racimisation ratio of aspartic acid,18 i.e. ratio between D-aspartic acid (D-Asp.) and L-aspartic acid (LAsp.) in dentin. AGE BY CLOSURE OF SKULL SUTURES1,3,5,6,11 Skull comprises of two parts — calvaria and face. Each of these comprises of smaller bones and they are presented in Table 11.8A.19-22 Bones of the calvaria are 8 in number, and they are: 2 parietal, one frontal, 2 temporal, one occipital, one sphenoid, and one ethmoid. Bones of the face and jaws are 14 in number: 2 maxilla, 2 zygoma, 2 nasal, 2 lacrimal, 2 palatine, 2 inferior nasal concha, one mandible and one vomer.

Chapter 11: Forensic Identity

Fig. 11.4A: Gustafson’s analysis of age changes in the teeth (left). Normal tooth (right). Criteria and ranking (Refer Tables 11.7 and 11.8)

Table 11.6: Criteria of age determination by Gustafson’s method/formula13,15 Changes assessed

Descriptions

Attrition* Periodontosis Secondary dentin Cementum apposition Root resorption Root transparency

Wearing down of incisal or occlusal surface due to mastication (macroscopically and microscopically) Retraction of gum margin and loosening of the tooth (macroscopically and microscopically) Seen within pulp cavity, due to aging/ reaction to caries and periodontosis (microscopically) At and around root of tooth (microscopically) Involves both cementum and dentin (macroscopically) Is best seen on ground section of tooth

* Cultural, dietary, pathological and traumatic factors affect the occlusal surface wear pattern44

Table 11.7: Gustafson’s ranking of structural changes in age determination Changes

Ranking and details

A = Attrition

A-0 A-1 A-2 A-3

No Attrition Attrition lying within enamel Attrition reaching the dentin Attrition reaching the pulp

P = Periodontosis

P-0 P-1 P-2 P-3

No Periodontosis Periodontosis just begun Periodontosis along first 1/3rd of root Periodontosis along 2/3rd of root

C = Cementum apposition

C-0 C-1 C-2 C-3

Normal A layer little greater than normal A great layer A heavy layer

R = Root resorption

R-0 R-1 R-2 R-3

No visible restoration Resorption only on small isolated spots Greater loss of substance More cementum and dentin affected

T = Root transparency

T-0 T-1 T-2 T-3

Transparency Transparency Transparency Transparency

not present just noticeable over apical 1/3rd of root over apical 2/3rd of root

71

Part III: Forensic Pathology Figs 11.4B to D: Age by cross striations of incremental lines of tooth enamel: (B) Mandible showing the location of the right incisor tooth enamel (smaller white box) sampled. (C) Close-up of enamel fragment with the area of interest, shown in second bigger white box. (D) Image showing growth lines (white arrows) with 10 daily lines between them (white brackets). The scale bar is 200 microns, or 0.2 mm. Source: http://www.esrf.eu/news/pressreleases/homo/ Retrieved on 21.07.2009

All the above bones are kept in position together by the flexible cartilaginous joints in early life. These are replaced by interlocking connections between bones on maturity.

Fig. 11.4E: Transverse section of premolar tooth root with alternate light and dark bands of cemental annulations (Arrow)

Table 11.8A: Bones of the Skull and their number

72

Skull Bones of Calvaria

Number

Bones of calvaria Parietal bone Frontal bone Temporal bone Occipital bone Sphenoidal bone Ethmoidal bone

02 01 02 01 01 01

Bones of face Maxilla Zygoma Nasal Lacrimal Palatine Inferior nasal concha Mandible Vomer

02 02 02 02 02 02 01 01

Total

08

14

Time of Fusion of Sutures (Table 11.9)1,3,5,6,11,20-22 (Refer Fig. 11.7A) Lateral and occipital fontanelle usually close within the first two months of birth. The anterior fontanella along with two halves of mandible closes at the second year. The condylar portion of occipital bone fuses with the squama at the third year and with the basi-occipital at the fifth year. The metopic suture closes at about the third year, but in 5-10 per cent cases it persists and the condition is called metopism (Refer Fig. 11.7B). The basi-occipit fuses with the basi-sphenoid at about 18-21 years. In the vault of the skull, closure of the sutures begins on the inner side 5-10 years earlier than on the outer side. The coronal, sagittal, and lambdoid sutures start to close on their inner side at the age of about 25 years. On the outer side, fusion occurs in the following order: posterior one-third of sagittal suture at about 30-40 years; anterior one-third of the sagittal and lower half of the coronal at about 40-50 years; and middle sagittal and upper half of coronal at about 5060 years. The lambdoid suture starts closing near the lambda and the union is often completed at about 45 years. The squamous part of temporal bone usually fuses with neighbor by the age of 60 years. Suture closure in skull occurs later in females than in males. However, estimation of age of skull from suture closure is not reliable as it can estimate age in a range of decade. Beginning union in the vault sutures may be identified by irregular radio-opacity on each side of the suture. For age estimation sagittal suture is the most reliable, followed by lambdoid and coronal sutures in order of frequency. A lateral head X-ray film is preferable for the study of coronal and lambdoid sutures. Ectocranial suture closure is very variable. Sometimes, there may not be ectocranial suture closure. This is called lapsed union. This occurs most often in the sagittal suture. With lapsing there is slight bony elevation on either

Criteria observed

Ages

Both inner and outer surfaces — Smooth and ivorine — Matted granular appearance Muscular markings become evident on — Sides of skull: Along the temporal line — On the occiput: Along nuchal line — On the lateral side of mandible: Along the mesenteric attachment Inner surface of skull: On either sides of the sagittal suture: Pits/depressions called — Pacchionian depressions develop and become more deeper and more in number — Middle meningeal artery groove becomes deeper Skull diploe: Becomes less vascularly channeled and increase with bone replacement.

Young adult age 40+/- 5 years 25 years onwards 25 years onwards 25 years onwards

Chapter 11: Forensic Identity

Table 11.8B: Other criteria of assessing the age of the skull

As age advances As age advances > 50 years

Fig. 11.5: Scheme of ossification of bones of upper extremity11

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Part III: Forensic Pathology

Table 11.9: Age by closure of skull fontanelle and sutures Fontanel and Sutures

Closing/Fusion*

Anterior fontanelle Mandible two halves Condylar portion of occipital bone with squamous Condylar portion of occipital bone with basi-occiput Lateral fontanelle Posterior fontanelle Metopic suture Basiocciput-Basisphenoid Coronal, sagittal, lambdoid begins fusion on inner side of vault Outer side of vault – Posterior 1/3rd sagittal – Anterior 1/3rd sagittal and lower 1/2 of coronal – Middle 1/3rd sagittal and upper 1/2 of coronal Lambdoid suture – begins closing at lambda and completes by Squamous part of temporal fuses with its neighbour by

2nd year 2nd year 3rd year 5th year 2nd month 2nd month/at birth? 2nd-3rd year 18 - 21 years 25 years 30 - 40 years 40 - 50 years 50 - 60 years 45 years 60 years

* The suture closure on outer aspect of the skull takes place 10 years after closure in the inner aspect

Fig. 11.6: Scheme of ossification of bones of lower extremity11

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Chapter 11: Forensic Identity

Table 11.10: Total number of bones in an adult human skeleton Skeletal structure

No. of bones

Skull with mandible Vertebral column (five sacral vertebrae fused together are taken as one and the three coccyx pieces are taken as one) Thoracic cage Upper limb Lower limb Total

29 26 25 64 62 206

Table 11.11: Ossification of sternum Part of sternum Manubrium sternum 1st piece of sternum 2nd piece of sternum 3rd piece of sternum 4th piece of sternum Xiphisternum

Appearance 6 months IUL* 6 months IUL 7 months IUL 7 months IUL 10 months IUL 3 years age

Fusion 20-25 yr At Puberty

50 yr 14 yr

40 yr

Old age

* IUL – Intrauterine Life

side of the incompletely closed suture. Apart from this, there are other approved methods of establishing age of the skull presented in Table 11.8B and Figures 11.7A, 11.10A to C and 11.11A to C. Ossification of Bones1-6,19-25,26 Human skeleton is comprised of 206 bones (Table 11.10). A detailed knowledge of ossification of bones, i.e. appearance and fusion of ossification centres can help in determination of the age of a person. Figures 11.5 to 11.18 and Tables 11.10 to 11.12, provide the scheme of ossification in human skeleton. Determination of age by skeletal changes constitutes the subject subdivision–forensic osteology. This is often useful when skeletal remains are recovered and partial/complete identity of the deceased has to be established from these remains.

Fig. 11.7B: Metopism. Note: metopic suture not fused (Courtesy: Capt. Dr B Santhakumar, Professor and HOD Forensic Medicine, Govt. Stanley Medical College, Chennai, TN)

Fig. 11.7A: Scheme of ossification of skull by suture closure (Inner aspect)

Fig. 11.7C: Radiograph (Towne’s view) showing craniostenosis— all skull sutures fused

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Part III: Forensic Pathology

Table 11.12: Age by changes in articular surface of the pubic symphysis (Refer Fig. 11.9) Changes noticed

Age

Markedly irregular and uneven with transverse ridges Ridges disappear, resulting in granularity and formation of the ventral and dorsal margins Symphyseal face becomes oval and smoothening of its upper and lower extremities Beaded rimmed margin Erosion of surface and break down of ventral margin Irregularly eroded surface

20 yr 24-38 yr 50 yr 5th decade 6th decade 7th decade

• Union of Xiphoid process with body of sternum—after 40 years (Table 11.11). • Lipping of lumbar vertebra or bones of the joints of the extremities—after 45 years (Fig. 11.7D). • Union of greater cornu of hyoid bone with body (40-60 years). • Rarefaction of bone i.e. senile osteoporosis—after 60 years • Age by changes in the articular surface of the pubic symphysis (Table 11.12 and Fig. 11.9). • Calcification of costal (30 years) and laryngeal cartilage (50±12.7 years).26 However, it may be noted that all these methods are not very reliable.

Fig. 11.7D: Lipping of lumbar vertebrae

Confirmation of Ossification Pattern A radiograph best confirms ossification pattern or union of ossification centres in a bone. Hence, always take an X-ray picture for confirming the age. The subject specialty dealing with this constitutes forensic radiology. The ideal site recommended/

Fig. 11.8: Age changes in the mandible

Fig. 11.9: Age changes of symphysis pubis (Refer Table 11.12)

Skeletal and Dental Changes Occurring in Advanced Old Age3,11,26 • Disappearance of skull sutures—after 60 years (Fig. 11.7C and Table 11.9). • Attrition or loss of teeth—after 50 years. 76

suggested for ascertaining the various ages of medicolegal importance are enumerated in Table 11.13 and illustrated in Figures 11.10 to 11.18. However, it may be remembered here that extent of ossification of bones varies, depending upon diet, hereditary and geographic factors.6

Age group

Radiograph/X-ray recommended

Infancy and childhood Adolescence age Adulthood Old age All age groups

Wrist and elbow Pelvis, hip and shoulder Elbow and knee Skull Pelvis, hip

Chapter 11: Forensic Identity

Table 11.13: Recommended radiograph/X-ray for different ages of medicolegal importance

Figs 11.10A to C: Foetal skull: (A) Frontal suture not fused, (B) Anterior fontanelle not closed, (C) Posterior fontanelle not closed

Figs 11.11A to C: Adult skull: (A) Basiocciput—basi-sphenoidal suture not fused, (B) Coronal and sagittal sutures—is not fused, (C) Sagittal suture—posterior 2/3rd fused

Figs 11.12A to C: Femur: (A) All centres fused, (B) Lower end not fused, (C) Upper end greater and lesser trochanter centres not fused (missing) and lower end not fused

Fig. 11.13: Iliac crest—not fused

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Part III: Forensic Pathology

Fig. 11.14: Mandible—age changes

Figs 11.15A to C: AP views of wrists of age groups: (A) 2-6 years (Reasons—Lower end of radius appeared: >2 years; Lower end of ulna not appeared: 10 years; Base of first metacarpal not fused 5 years; centre for upper end of ulna not appeared: 9 years; Centres for upper ends of both radius and ulna not fused: 14 years but not fused: 12 years; Centre for iliac crest not appeared: 14 years; Centre for Ischial tuberosity not appeared: 17 years; iliac crest not fused: 20 years)

Changes in Sacrum and Vertebrae Helpful in Determining the Age Sacrum The five sacral vertebrae are separated by cartilage until puberty. Later, fusion of epiphyses takes place and ossification of intervertebral discs extend from below upwards. Sacrum becomes single bone at 21-25 years of age, leaving a gap between S1 and S2, until 32 years due to ‘lapsed union’.

between 21 and 25 years. Later on, due to osteo-arthritic changes in the form of lipping of vertebra are seen after the age of 45 years.

Vertebrae The immature vertebral body has series of deep radial furrows both on upper and lower surfaces. The feature increases in prominence up to the age of ten, and then gradually fades

HEIGHT AND WEIGHT DATA Height and weight data are quite useful in establishing age of a person. Table 11.14 presents these facts clearly.7 This table is rather often useful in determining the normal height and weight range for a given age.

Miscellaneous Data Various other data that may be worth mentioning and beneficial in determining the age of an individual are enumerated below:

Table 11.14: Age by height and weight data (Standard heights and weights for men and women— by Life Insurance Corporation of India)

Height Metres

0’. 0”

1.523 1.5484 1.5738 1.5992 1.6246 1.650 1.6754 1.7008 1.7262 1.7516 1.7770 1.802 1.8278 1.8532 1.8786 1.9040

5’ 0” 5’ 1” 5’ 2” 5’ 3” 5’ 4” 5’ 5” 5’ 6” 5’ 7” 5’ 8” 5’ 9” 5’10” 5’11” 6’ 0” 6’ 1” 6’ 2” 6’ 3”

kg

Men (Weight) lb

…. …. 56.3 – 60.3 57.6 – 61.7 58.9 – 63.5 60.8 – 65.3 62.2 – 66.7 64.0 – 68.5 65.8 – 70.8 67.6 – 72.6 69.4 – 74.4 71.2 – 76.2 73.0 – 78.5 75.3 – 80.7 77.6 – 83.5 79.8 – 85.9

…. …. 124 – 133 127 – 136 130 – 140 134 – 144 137 – 147 141 – 151 145 – 156 149 – 160 153 – 163 157 – 168 161 – 173 166 – 178 171 – 184 176 – 189

Women (Weight) kg 50.8 – 54.4 51.7 – 55.3 53.1 – 56.7 54.4 – 58.1 56.3 – 59.9 57.6 – 61.2 58.9 – 63.5 60.8 – 65.3 62.2 – 66.7 64.0 – 68.5 65.8 – 70.3 67.1 – 71.7 68.5 – 73.9 ….. …. ….

lb 112 – 120 114 – 126 117 – 125 120 – 128 124 – 132 127 – 135 130 – 140 134 – 144 137 – 147 141 – 151 145 – 155 148 – 158 151 – 163 ….. ….. …..

Note: Maximum weight that one may reach: Up to the age of 30 years, 10% above standard, between 30 to 35 years, standard is optimum weight, above 35 years, 10% below standard 79

Part III: Forensic Pathology

• Pubic hair: They appear at the age of about 13 years in female and at the age of 14 years in male. They are sparse, soft and light in colour initially and later on turn thick, bushy and dark within 2 years of appearance with the onset of puberty (Fig. 11.19A). • Axillary hair: They appear at the age of about 14 years in female and at the age of 15 years in male. • Beard and moustache/facial hair: They appear only in male by 16 to 18 years.

• Breasts: Begin to appear by 13 to 14 years in females only (Fig. 11.19B). • Voice: It become hoarse in males by 16 to 18 years. • Scalp hair: Begins to turn gray by 40 years. Also becomes less dense as the age advances. • Axillary and pubic hair: Turn gray only at advanced old age. • Arcus senilis: This is a whitish ring that makes its appearance in the periphery of the cornea of the eyes due

Fig. 11.19A: Secondary sexual characteristics pertaining to vulva and pubic hairs

80

MEDICOLEGAL IMPORTANCE OF AGE1-6,11,23-24,28-33 Medicolegal importance of age is multifaceted. Enumerated below are certain important ones, which a doctor has to be aware of:

• In identification of the individual: Unless the age of a person is determined the identity of the person live or dead stands incomplete. • Embryo and pregnancy: On 7th day of fertilisation, ovum getting impregnated in the uterus, is called as “embryo” and the woman is said to be “pregnant”. • Foetus and foeticide: From 2nd lunar month (or 8th week IUL), embryo is termed as “foetus” and killing of a foetus is (foeticide).

Chapter 11: Forensic Identity

to the degenerative changes and begins at about the age of 40 years, is a normal process of aging (Figs 11.19C and D). • Cataract (opacity of lense) in the eyes: It is seen in old age (>60s). • Wrinkles over the face: Are seen in old age (>60s).

Fig. 11.19B: Secondary sexual characteristics pertaining to the breast

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Part III: Forensic Pathology Figs 11.19C and D: (C) Normal eye (D) Eye with arcus senilis

82

• Viable child (Sec 300 IPC): After 7 calendar months (210 days) of pregnancy, fetus is called as “viable child” as it can live independently if born and killing of a viable child amounts to the offence of “infanticide”. • Full-term foetus: Foetus after 10 lunar months of pregnancy is called as “full-term foetus”. • Medical termination of pregnancy (MTP)-induction: Inducing MTP, decision by one doctor is allowed up to 3 lunar months (12 weeks IUL) of pregnancy and beyond this period decision is always by two doctors (MTP Act, 1976). However, beyond 5 lunar months (20 weeks IUL) of pregnancy, MTP is not done, unless otherwise mother (pregnant woman) is gravely ill. • Still-born: Foetus after 28 weeks of IUL if shows no signs of life or any breathing is called as “still-born”. • Criminal responsibility: In law the crime and punishment is entirely based on criminal responsibility, and this in turn is dependent on age of a person and may be highlighted as follows briefly: – Under Section 82 IPC, law presumes that a child below 7 years is incapable of committing any crime.27,47 – Under Section 83 IPC, however, children between ages of 7 and 12 years will be guilty of offence and held responsible for the offenses charged, only if the trying court is satisfied that the child has attained sufficient degree of mental maturity of understanding to judge the nature of consequences of their acts on that occasion and unless proved to the contrary.27,47 – Under Section 127-130 of Indian Railway Act, 1890, children above 5 years of age are held liable for punishment if he/she does anything maliciously to wreck or attempt to wreck a train and passengers in it or to railway property.30,49 – However, all child offenders above the age of 12 years but below 18 years are called juvenile offenders and tried in a juvenile court and are sent to Borstal or juvenile reformatory schools and not to a jail (Juvenile Justice Act, 1986).50 • Infanticide: Deliberate and unlawful killing of a newborn or a child below the age of 1 year by the act of omission or commission is considered as infanticide. Infant is any live born child up to the age of one year after birth and infanticide is regarded as murder in the court of law and is punishable under Section 302 IPC.47

• Marriage: Any matrimonial alliance entered into by a boy below 21 years and girl below 18 years will be invalid (Child Marriage Restraint Act, 1978). • Kidnapping: To constitute an offence of kidnapping or abducting a minor from lawful guardianship, the age should be 10 years for the purpose of movable property from the body of the child or in its possession (Section 361 IPC), below 16 years for a boy and below 18 years for a girl; inducing any girl of Indian origin below 18 years (Section 366 IPC)/below 21 years when imported from Jammu and Kashmir or any outside country for the purpose of illicit sexual intercourse (Section 366-B IPC) also constitutes the offence of “kidnapping” and is punished by 10 years imprisonment and with/without fine. • Rape: Sexual intercourse with a girl below 16 years, even with her consent, legally constitutes rape (Statutory rape). However, as child marriage is still in prevalence in India, even this day, sexual intercourse by a man with his own wife who is of age 15 years) of age to work in a nonhazardous work during day time, provided that he has been certified by a physician to be fit physically. • Age and government employment: In India, minimum age limit for entering into the government services is 18 years while the age of retirement from government service, ranges from 55-58 years. Note: However, both may vary depending on the job and the State Government Policies. • Consent: A child below 12 years cannot give consent for physical examination and the valid consent is to be given by the parents/guardian (Section 89 IPC).47 However, valid consent for suffering any harm not intended or known to

SEX AND IDENTITY1-6,8,9,11,22-26 Sex of person is equally important as the age factor in determining the identity of an individual. Sex of a person alive or dead can

be determined by: (i) physical examination, (ii) gonadal biopsy, (iii) sex chromatin, and (iv) other methods. Physical Examination This includes traits establishing sex identity of an individual. This constitutes anatomical sex component that determines sex and comprise of external appearances inclusive of external genitalia in male and female and internal genital tract in the female (Figs 11.20A to C).

Chapter 11: Forensic Identity

cause death/grievous hurt, for example, major surgical operation, can be given only if he/she is above 18 years of age (Section 87 IPC).47 Table 11.15 lists various ages of medicolegal importance in an ascending order of age (from birth to old age) for an easy understanding and recollection.

Table 11.15: Medicolegal importance of age Age in Years

Medicolegal Importance

7 days of fertilisation 08 weeks IUL 12 weeks IUL >12 weeks 20 weeks IUL >28 weeks IUL 07 months IUL (210 days) 10 months (lunar) 140 weeks IUL 0-1 year 5 years 7 years 10 years 12 years 14 years 15 years 16 years 18 years

Embryo, pregnancy Foetus Induction of MTP – one doctor can decide Induction of MTP – two doctors should decide Induction of MTP – Not allowed unless for serious maternal causes Called ‘stillborn’ if no sign of life/breathing Viable child; if killed – charges of infanticide Full term foetus Infanticide Indian Railway Act Criminal responsibility Kidnapping for valuables Consent for physical examination Factory employment Act Consent for sexual intercourse in married woman Valid consent for sexual intercourse by a woman (Statutory Rape), Kidnapping charges (Boys), etc Consent for major surgery, attaining majority, right to franchise vote, kidnapping charges (Girls), marriage (Girls), minimum age for entering Government service, upper limit for juvenility, etc. Attaining majority when under court guardianship, marriage (Boys) Minimum age for contesting membership of Indian Parliament/Other legislative bodies Age limit for entering in to government services Minimum age for appointment as the President (Vice-President), Governor of a State in India Menopause in a woman usually Age of retirement from government service, government undertakings, statutory bodies, autonomous bodies/ institutions, higher judiciary services

21 years 25 years 28 years 35 years 41-45 years 56-58 years

Fig. 11.20A: Male external and internal genitalia: (1) Male external genitalia viewed from the front: p—penis, pp—prepuce, s—scrotum, t—testis, vd—vas deferens, (2) Male internal genitalia viewed from the front: gp—glans penis, pr—prostate, sv—seminal vesicle, u— urethra, ub—urinary bladder, ur—ureter, vd—vas deferens, and (3) Midsagittal section of the male pelvis showing external and internal genitalia: p—penis, pr—prostate gland, r—rectum, s—scrotum, u—urethra, uv—urinary bladder

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Part III: Forensic Pathology Fig. 11.20B: Female external and internal genitalia: (1) Female external genitalia: c—clitoris, h—hymen, l—labia minora, lm—labia majora, u—urethral meatus, v—vaginal opening, (2) Female internal genitalia viewed from the front: cc—cervical canal, cx—cervix, f—fundus, fi—fimbriae, ft—fallopian tube, o—ovary, v—vagina, and (3) mid-sagittal section of the female pelvis showing external and internal genitalia: lm—labia majora, o—ovary, r—rectum, u—urethral meatus, ub—urinary bladder, ut—uterus, v—vagina

Fig. 11.20C: Histology of testes and ovary

Table 11.16 enumerates the external and internal genital organs in establishing the differences between male and female sex. Gonadal Biopsy Gonadal biopsy is a confirmatory method of determining sexual identity histologically (Fig. 11.20C). This constitutes “gonadal sex” component in determining sex. In all disputed sexual identity cases, gonadal biopsy is suggested.20,34

Table 11.16: Traits establishing sexual identity

84

Traits

Male

Female

Testes

Present, functioning

Absent

Penis

Present

Absent

Ovary

Absent

Present

Uterus

Absent

Present

Vagina

Absent

Present

Shoulder

Broader than hips

Narrower than hips

Gluteal region

Flat

Full and rounded

Adam’s apple

Prominent

Less prominent

Breasts

Absent

Grows at puberty

Pubic hairs

Thick and extends to umbilicus only

Thin and covers up only the mons pubis

Sex Chromatin (Barr and Davidson Bodies)8,9,11,35-37 A chromosome that determines whether an individual is male or female represents sex chromosome. This constitutes chromosomal sex or nuclear sex component in determining the sex. The sex chromosomes in human beings are designated as X and Y chromosome. In humans the sex chromosomes comprise just one pair of the total of 23 pairs of chromosomes. The other 22 pairs of chromosomes are called autosomes. The individual having two X-chromosomes (XX) is female, while individual having one X and one Y-chromosome (XY) is male. The X-chromosome resembles a large autosomal chromosome with a long and a short arm. The Y-chromosome has one long arm and a very short second arm. This change into maleness or femaleness takes place at the moment of meiosis, when cell divides to produce gamete. Thus during meiosis, the male XY sex-chromosome pair separates and passes on a X or a Y to separate gametes, the result is that one-half of the gametes (sperm) that are formed contains the X chromosome and other half contains the Y-chromosome. The female has two X-chromosomes, and all female eggs normally carry a single X. Thus, the eggs with X-chromosome when fertilised by Xchromosome bearing sperm the offspring will become a female with XX-chromosomes, whereas those fertilised by Y-chromosome bearing sperm become males (XY). The X-chromosome in a female is seen in the form of chromatin condensation towards the nuclear membrane microscopically in the nucleus of a cell. This condensed chromatin has been shown to consist of deoxyribose nucleic acid, 1 µ in size and is present in approximately 75 per cent of female cells.

Buccal Smear From a normal female, sex chromatin appears as a small planoconvex mass, lying near nuclear membrane (Fig. 11.21A) microscopically. Thus, based on this, to diagnose female sex, the buccal smear must exhibit minimum of 20 to 30 per cent Barr bodies, as against 0 to 4 per cent Barr bodies detected in normal male (Fig. 11.21B).35

Chapter 11: Forensic Identity

It is called as sex chromatin or Barr body. Usually, they are better appreciated in the cells of skin, buccal mucosa, cartilage, nerves, amniotic fluid and lymphocytes. Barr and Bertram first described this in the nucleus of the nerve cells of female cat, and coined the terminology Barr body.35 This turned out to be of great significance in identifying the true sex (nuclear sex) of a person in case of intersex individual with malformed sex organs.37

Fig. 11.21A: Barr body in buccal smear

Vaginal Epethilial Cell (PAP Smear) Figure 11.21C illustrates Barr body in it is from a normal adult female, is presented here for the purpose of familiarising it to a reader. Peripheral Blood Smear Neutrophilic leukocytes in a normal female often presents a similar and distinctive type of nuclear appendage attached to one of the nuclear lobe, resembling a drumstick (Fig. 11.22). This is known as Davidson body. However, to diagnose sex as female by this, the peripheral smear examined must show minimum 3 per cent counts.3,6,38 Other Methods Newer methods reported in recent forensic literature are worth mentioning here, adding to the existing list of factors, establishing sex in disputed sex identity cases. Additional factors marking recent advances in sex determination are: (i) costal cartilage calcification pattern,45,46,57 (ii) footprint ratio,58 and (iii) mandibular canine index (MCI),59,60 (iv) cytogenetics and DNA analysis, (v) counting of sex materials within the nucleus.

Fig. 11.21B: Planoconvex chromatin mass of Barr bodies (arrows) in buccal smear (40x)

Costal Cartilage Calcification Pattern In this methodology radiological appearance of the calcification pattern of costal cartilage (5-12th rib) is considered in determining the sex in age group 16 to 20 years. Three distinct patterns are described under this (Fig. 11.23). This is the first Indian classification pattern ever reported and known as Rao and Pai’s classification of calcification pattern.57 Accuracy of the method is >92.3 per cent. Footprint Ratio (FPR) This is the ratio between maximum width (MW) and maximum length (ML) of the footprint in millimeters and is reported to be useful in establishing sexual identity of a person alive or dead. Figure 11.24, below gives an idea as to how these parameters are measured and applied in determining the sex. Maximum width of the footprint (MW) FPR = ______________________________________________________ Maximum length of the footprint (ML)

Footprint ratio (FPR) value being derived using this formula is then compared with standard footprint ratio (SFPR) value (0.376 for left foot and 0.377 for right foot). Sex is predicted as female when the FPR values derived are within the limits of SFPR, and as male when the limits are crossed. Accuracy of the method is 78 per cent.58

Fig. 11.21C: Vaginal epethilial cell Papanicolaou (PAP) smear–arrow pointing at the bar body (Courtesy: Dr Uday Pal Singh, KMC, Warangal, AP)

Mandibular Canine Index Mandibular canine index (MCI) is again a ratio of maximum width of the permanent mandibular canine (mesiodistal crown width) to arch width. Figure 11.25 gives an idea as to how these parameters are measured and applied in determining the sex. MCI values being derived thus using this formula are then compared with standard mandibular canine index (SMCI) value

85

Part III: Forensic Pathology Fig 11.22: Davidson body in peripheral smear

Fig. 11.24: Parameters to be measured in deriving the sex identity by foot-print ratio (FPR)58

Type A - Marginal square bracket type (Common male type) Type A1 - Marginal linear type (Less common male type) Type B - Central tongue shaped type (Female pattern) Fig. 11.23: Costal cartilage calcification pattern in establishing sex identity57

(0.274) and sex is predicted as female when the values derived are within the limits of SMCI, and as male when the limits are crossed. The accuracy of this method is reported to be 85 per cent.59,60

Cytogenetics and DNA Analysis This is a powerful tool in sexing which can replace all older techniques in future.52-54 Counting of Sex Material within the Nucleus Stained with a fluorescent dye and viewed with U-V light, performed on the neurons in a brain smear or on cells from the kidneys.

86

Sex Determination in a Dead Body Sex determination in dead body is rather easy, provided the deceased is normal physically. However, in dead bodies in mutilated or highly putrefied condition or skeletonized state, sex determination poses challenging task and methods opted

Fig. 11.25: Mandibular canine index in sex determination (AA1Mesiodistal width; BB1 mandibular canine arch width) in establishing sex identity

routinely are: (i) meticulous autopsy examination of internal genital tract, and (ii) skeletal examination.1-6,11

Meticulous Autopsy Examination of Internal Genital Tract Due to presence of intact external and internal genital system in a recently dead body, it may not be difficult to establish sexual identity. However, presence of uterus and appendages in a nulliparous woman and prostate in a man can confirm the sex of an individual, even in a highly decomposed cadaver.1-6 Skeletal Examination11,22,23 Skeletal remains or bones are also helpful in establishing sexual identity. Sexing the skeleton, which is intact and entire, is certainly easier as against only a part of the skeleton that is available. Table 11.17 as notified by Krogman, gives an idea regarding the percentage accuracy of sexing by skeletal remains. Diagrammatic representation of skeletal findings in favour of

Skeletal remains/bones

Accuracy (%)*

Entire skeleton Skull + pelvis Pelvis + long bones Skull + long bones Pelvis alone Skull alone Long bones only

100 98 98 95 95 93 85

* Adopted from Krogman WM, in ‘The human skeleton in Forensic medicine’, Charles C Thomas, Illinois, USA, 196223

sex determination is provided in the form of photographs (Figs 11.26 to 11.30) and also in tabular form in Tables 11.18 and 11.19. Medicolegal Importance of Sex Identity Medicolegal significance of sexual identity can be discussed under following subheadings: • Concealed sex • Intersex. • Psychological sex • Environment and upbringing.

Chapter 11: Forensic Identity

Table 11.17: Accuracy in determining sex identity by skeletal remains

Concealed Sex Criminals may try to conceal their sex to avoid detection by Police by changing dress and other means. In cases of individuals

Figs 11.26A to C: Male and female skull: (A) Anterior view, (B) Lateral view, (C) Superior view

87

Part III: Forensic Pathology Fig. 11.26D: Male and female skull—inferior view

Fig. 11.28: Male and female innominate—posterior view

Fig. 11.29: Sacrum—anterior view; male and female

Figs 11.26E and F: Male and female mandible (E) Anterior view, (F) Inferior view

Fig. 11.30: Femur: anterior view male and female

who are suffering from acquired or congenital sexual abnormalities an attempt may be made to conceal the sex. Simple undressing of the person in a doubtful case will be sufficient to know the true sex or otherwise.

Figs 11.27A and B: Pelvis in male and female (innominate and sacrum): (A) Anterior view, (B) Superior view

88

Intersex Sexual differentiation and normal subsequent development are fundamental to the constitution of the human species. Intersex means intermingling of sexual characteristics of either sex in one individual to a varying degree, including the physical form, reproductive organs and sex behavior. There are several types of intersex and four types are recognized medico legally and

Bone features Skeleton in general Size Weight

Male

Female

Large, massive 4.5 kg

Small, slender 2.75 kg

Irregular and rough Prominent Prominent Prominent Rounded Rectangular and small

Smooth and fine Less prominent Less prominent Less prominent Sharp Round and large

Less prominent Less prominent

More prominent More prominent

U-shaped More prominent More prominent Large More prominent

Parabola Less prominent Less prominent Small Less prominent

Larger, thick Square or U-shaped Less obtuse Everted Larger

Small, thin V-shaped More obtuse Not so Smaller

Heart-shaped Conical and funnel-like Narrow (V-shaped)

Circular/oval Broad and round Wide: U-shaped

Faint/absent Small narrow and deep Triangular Inverted

Well marked Large, wide and shallow Square Everted

Size Length Width Curvature Sacral promontory

Large, narrow More Less Uniform Prominent

Small, broad Less More Abrupt Less prominent

Head Neck-shaft angle Bicondylar width

Large, 2/3rd sphere Wider More

Small, not 2/3rd sphere Narrower Less

Skull Anterior surface Frontal surface Glabella Supra-orbital ridge Zygoma Supra-orbital margin Shape of the orbit Superior surface Frontal eminence Parietal eminence Inferior surface Palate Articular facets Mastoid process Foramen magnum Occipital protuberance Mandible Size Chin (symphysis mentii) Angle: body-ramus Angle of mandible Condyles

Chapter 11: Forensic Identity

Table 11.18: Sex differences in human skeleton (Figs 11.26 to 11.30)

Pelvis Pelvic brim/inlet Pelvic cavity Subpubic angle Hip bone (innominate) Preauricular sulcus Greater sciatic notch Body of pubis Ischial tuberosity Sacrum

Femur

they are: (i) gonadal agenesis, (ii) gonadal dysgenesis, (iii) true hermaphrodites, (iv) pseudohermaphrodites and (v) hormonal intersex.8,9 Gonadal agenesis: In gonadal agenesis testes and ovary have never developed. Nuclear sex is negative. Gonadal dysgenesis: In gonadal dysgenesis, the external sexual structures are present, but at puberty the testes/ovaries fail to develop, e.g. Klinefelter’s syndrome, Turner’s syndrome.

• Klinefelter’s syndrome: Anatomically male (Fig. 11.31) but nuclear sex is female. Sex chromosome pattern is XXY (47 chromosomes). Presence of ‘Y’ chromosome gives resemblance to the male, and these individuals are chromatin +ve, like a female because of the extra ‘X’ chromosome. Characteristic features are - they resemble male externally in general body conformity, with smaller/normal size penis with smaller testicles normally placed. Sterility is common, gynecomastia is present frequently, with a high pitched voice, 89

Part III: Forensic Pathology

Table 11.19: Mathematical sexing of bones

Bones

Parameters measured

Male

Female

Atlas

Breadth

83.00 mm

72.00 mm

Humerus

Length/ Vertical diameter—head Bicondylar width

322.00 mm 48.00 mm 60.00 mm

290.00 mm 40.50 mm 57.50 mm

Radius

Length Vertical diameter—head

242.00 mm 22.50 mm

201.20 mm 21.50 mm

Femur

Length Vertical diameter—head Bicondylar width

439.00 mm 48.00 mm 79.50 mm

412.00 mm 41.00 mm 70.50 mm

Tibia

Length Bicondylar width

370.00 mm 74.00 mm

358.00 mm 65.80 mm

Indices

Ischiopubis index Sciatic notch index Sacral index Corporobasal index Sternal index

83.60 4-5 112.00 45.00 46.20

99.50 5-6 116.00 40.50 54.30

giving a eunchoidal appearance. Testicular biopsy usually reveals hyaline degeneration of the seminiferous tubules as a result of which sterility is the presenting symptom. • Turner’s syndrome: Anatomically female (Fig. 11.32), but the nuclear sex is male. Sex chromosome pattern XO (45 chromosomes). Absence of ‘Y’ chromosome gives the individual resemblance to the female, but individual will be chromatin negative, i.e. there will be no Barr bodies or drum sticks in the neutrophils. Vagina and uterus if present are undeveloped. Person will be of short stature, will have oedema of hands and feet, wide carrying angle, broad chest with widely placed nipples and webbed neck. Occasionally individual will have associated features such as colour blindness, coarctation of aorta and short metatarsals with deformities of digits (cubitus valgus), etc. As they reach puberty, they fail to present with secondary sexual characteristics, as they posses streak ovaries, which are incapable of producing oestradiol. True hermaphrodites: This is a condition of bisexuality. Here both ovary and testis (ovotestis) with external genitalia of both sexes exist in one individual. Sex chromatin may be of either male or female pattern. According to Watanabe there are 3 varieties of true hermaphrodism.62 1. Bilateral true hermaphrodism: There is a testis and an ovary (ovotestis) on each side (Figs 11.33A and B).

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Figs 11.31A to D: Klinefelter’s Syndrome. Above: Illustration of clinical manifestations (A) Below: Case of Klinefelter’s Syndrome (anatomically male but nuclear sex female)—adolescent male. Note: Gynaecomastia and no chest hairs (B); Smaller penis, normally placed but smaller testicles, feminine distribution of pubic hair (C). Testicular biopsy — hyaline degeneration of seminiferous tubules (D)

Pseudohermaphrodite: It could be of two subtypes: • Female pseudohermaphrodites has male external features, but internally has the female gonads (Fig. 11.33E).

• Male pseudohermaphrodites has female external features, but internally has the male gonads (Fig. 11.33F). Hormonal intersex: Sexual variation could be due to the hormones. In the female pseudohermaphrodites, an excess production of androgenic hormone by adrenal cortical hyperplasia can modify the external genitalia of a genetic female. Hypertrophy of the phallus, fusion of the labia majora and hirsutism may cause the parents to consider their child to be a male. The virilising tumours of the ovary, such as arrhenoblastoma, can cause hirsutism, hypertrophy of the clitoris, deepening of the voice, masculine body contours and amenorrhoea. The presence of estrogen in the male can cause gynecomastia. These are all examples of how hormones, natural or therapeutic, can modify the sexual organs and secondary sexual characteristics.

Chapter 11: Forensic Identity

2. Unilateral true hermaphrodism: There is a testis and an ovary (ovotestis) on one side and either a testis/an ovary on the other side (Figs 11.33C and D). 3. Alternating true hermaphrodism: There is testis on one side and the ovary on the other side.

Psychological sex: Many men and women are psychologically dominated towards sexual inversion, a persistence of the childhood tendency. Behaviour, speech, dress and sexual inclination proclaim this fact. Transvestism and effeminate behaviour are the most obvious and complete examples, where men dress in women’s clothes and assume that gender role, and vice versa. Environment and upbringing: This decides the sex of rearing. There are many examples of genetic males and females being reared by their parents in the mistaken sexual category, and who have acquired over the years the habits and mental inclination of the opposite sex to a sufficient degree to pass off as members of the opposite sex. IDENTITY BY OTHER FACTORS Various important other factors helpful in establishing identity are—racial characters, dactylography, poroscopy, footprint, complexion, features, hair, stature, deformities, tattoo marks, scar, occupational stigmata, anthropometry, trace evidence factors, etc. Race and Racial Characters These are discussed mainly under the speciality field of Forensic Anthropology. Increase in mass disasters often utilises race and

Figs 11.32A to D: Turner’s syndrome: Above: Illustration highlighting the clinical manifestations (A). Below: Case of Turner’s syndrome (anatomically female with nuclear sex male). Note: short stature, web neck, wide carrying angle, oedema of hands and feet, broad chest with widely placed nipples, cubitus valgus, lack of secondary sexual characteristics at puberty (B). Comparative histopathology ovary— Normal ovary with eggs (C), Streak ovary with no eggs (D)

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Part III: Forensic Pathology Figs 11.33A and B: Bilateral true hermaphrodite: (A) Well developed phallus, bilateral ovotestes, with fish mouthed urethra below the phallus and vaginal opening in between scrotal sacs (B) Histopathology of ovotestes showing - ovarian component forming a crown around the testicle parenchyma

Figs 11.33C to F: (C and D) Unilateral true hermaphrodite with ambiguous external genitalia. (C) Well-developed phallus and right scrotal ovotestis and testes on left side. (D) Penoscrotal hypospadias. (E) Female pseudohermaphrodite with male external features with a hypertrophied clitoris and fused labia but has female gonads internally; (F) Male pseudohermaphrodite with female external features but has male gonads internally (Source: Shilpa Sharma and DK Gupta, Male genitoplasty for intersex disorders. Advances in Urology: Volume 2008 (2008). Article ID: 685897)

racial characteristics in establishing the identity of victims.23,27,65 According to the anthropological sciences, there are three primary races in the world – Caucasoid, Mongoloid and Negroid. However, as per Blueman Backs classification there are five human races on the basis of skin colour,5 and they are: 1. Caucasian (white) 2. Mongoloid (yellow) 92

3. Ethiopian (black) 4. American (red) 5. Malayan (brown). Most of the Indians show Caucasoid features. However, Mongoloid features are more common in the North-Eastern population, while, some of the Negroid features are common among the Southern Indian population.29,63 Race determination usually depends on following:

Traits

Caucasian

Mongoloid

Negroid

Population (Original) Skin Iris Hairs (Scalp)

Europeans Thin and fair Blue/gray Thin, straight or wavy, with fair/light brown/ reddish colour

Chinese Pale and yellow Black Straight or wavy with black colour

Africans Tought and black Black Curley and wooly with black colour

Flattened

Small and compressed Big and full

Small Small

Longer forearms than arms Longer legs than the thighs Obliquely placed (proclenated) with outward projection

Face Lips Extremities • Upper • Lower Teeth

Lower 1st premolars may have 3 cusps and both permanent and temporary molars will have 3 roots

Skull: • Shape • Size • • • •

Round Mesaticephalic (intermediate) 75-80 Raised

Cephalic index Forehead Orbits Nasal aperture

Narrow

Square Brachycephalic (small)

Narrow and oblong Dolicocephalic (large)

80-85 Inclined High and roundish

70-75 Small and compressed Low and wide Broad and wider

Chapter 11: Forensic Identity

Table 11.20A: Differences in morphologic feature/traits of three primary races of world population

Table 11.20B: Osteometric indices (refer Table 11.20C) helpful in determining the races Various indices Cephalic Index Brachial Index Crural Index Humero-femoral Index Inter-membral Index

Caucasian

Values Mongoloid

Negroid

(Please refer the Table 11.20D) Average Europeans 74.5 Average Europeans 83.3 Average Europeans 69 Average Europeans >70

— — — —

Average Average Average Average

Negroids Negroids Negroids Negroids

78.5 86.2 72.4 14 cm

Site

Vital parts

Size

Largest (> 2.5 cm)

Smaller

Smallest*

2.5-4 cm

Shape

Irregular**

Circular

Circular

Rat hole*

Edges:

Scorched and contused

Well defined and inverted

Mid to distant range

Any where on the body

Irregular and lacerated

— Central big wound with smaller wounds around

— Wider spread

— Spread is not measurable

—

—

—

Blackening

+++

+++

++

+

—

—

—

Tattooing

+++

++++

+++

++

—

—

—

Singeing

+++

++++

++

—

—

—

—

* Both are called as close range ** Irregularly circular with crenated and scalloped edges Note: 1. Close-range shotgun wounds can be as destructive as those from a high-velocity rifle, however, longer the weapon-victim rangeinjury produced is minimal. 2. The type of shot (size and weight of pellets) used also determines the type of injury, usually more serious injuries are produced by the larger type of buckshot (greater than 0.14 inches in diameter).

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Blow Back Effect It may be compared to the blast effect of a gunshot wound. Mechanism mainly involved is that in contact shot or close shot range firing, the gases evolved may get accumulated under the skin resulting in a bigger wound of entry, muzzle end imprint

abrasion, distortion of the face when shot with muzzle end kept pressed against the roof of the mouth, etc. Billiard ball ricochet effect — This is a peculiar effect wherein though the firing is done at close range, the appearance of the

Earlier Testimony from Dallas Doctors The back wound The death certificate, signed by the President’s personal physician Dr. Burkley, an Admiral in the U.S. Navy, gave a location for the back wound lower than found by the later autopsy (either its photographs or measurements). Dr. Burkley believed a bullet to have hit Kennedy at “about” the level of the third thoracic vertebra. Supporting the location of Dr. Burkley is a diagram from the autopsy report of Kennedy, which shows a bullet hole in the upper back. However, this diagram is freehand and not drawn with any attention to landmarks — a criticism made of it by the later HSCA analysis. Burkley’s location at T3 is also about the same location of the bullet hole in the President’s shirt and the bullet hole in the suit jacket worn by Kennedy, which shows bullet holes between 5 and 6 inches below the top of Kennedy’s collar. However, again there has been controversy on the matter of whether or not the holes in the president’s clothing should be expected to correspond to the location of his back wound, since he was sitting with a raised arm at the time of the assassination, and multiple photographs taken of the motorcade show his suit jacket bunched at the back of his neck and shoulder, so that it did not lie closely against his skin.

Chapter 20: Firearms and Explosive Injuries

John F Kennedy Assassination — Autopsy33,34 John F Kennedy, was the Thirty-Fifth President of USA, Term: 1961-1963, was born on May 29, 1917 in Brookline, 32 Massachusetts, died on November 22, 1963, was killed by an assassin’s bullet in Dallas, Texas. He was married to Jacqueline Lee Bouvier Kennedy. The autopsy of President John F. Kennedy was performed, beginning about 8 p.m. and ending about midnight EST, on Nov. 22, 1963, the day of his assassination, at the then Bethesda Naval Hospital in Bethesda, Maryland. The choice of autopsy hospital in the Washington, D.C. area was made at the request of Mrs. Kennedy, on the basis that John F. Kennedy had been a naval officer.

Official Findings of the Autopsy The missile wound in the back 1. The Bethesda autopsy physicians attempted to probe the bullet hole in the base of Kennedy’s neck above the scapula, but were unsuccessful as it passed through neck strap muscle. They did not perform a full dissection or persist in tracking, as throughout the autopsy, they were unaware of the exit wound at about the same level, at the front of the throat. Emergency room physicians had obliterated it when they performed the tracheostomy. 2. At Bethesda, the autopsy report of the president, Warren Exhibit CE 386 described the back wound as being oval, 6 × 4 mm, and located “above the upper border of the scapula” [shoulder blade] at a location 14 cm (5.5 in) from the tip of the right acromion process, and 14 cm (5.5 in) below the right mastoid process (the bony prominence behind the ear). 3. The concluding page of the Bethesda autopsy report, states: “The other missile [the bullet to the back] entered the right superior posterior thorax above the scapula, and traversed the soft tissues of the supra-scapular and the supra-clavicular portions of the base of the right side of the neck. 4. The report also reported contusion (bruise) of the apex (top tip) of the right lung in the region where it rises above the clavicle, and noted that although the apex of the right lung and the parietal pleural membrane over it had been bruised, they were not penetrated, indicating passage of a missile close to them, but above them. The report noted that the thoracic cavity was not penetrated. 5. This missile produced contusions of the right apical parietal pleura and of the apical portion of the right upper lobe of the lung. The missile contused the strap muscles of the right side of the neck, damaged the trachea, and made its exit through the anterior surface of the neck.” 6. The single bullet theory of the Warren Commission Report places a bullet wound at the sixth cervical vertebra of the vertebral column, which is consistent with 5.5 inches (14 cm) below the ear. The Warren Report itself does not conclude bullet entry at the sixth cervical vertebra, but this conclusion was made in a 1979 report on the Kennedy assassination by the House Select Committee on Assassinations (HSCA), which noted a defect in the C6 vertebra in the Bethesda X-rays, which the Bethesda autopsy physicians had missed and did not note. 7. Even without this information, the original Bethesda autopsy report, included in the Warren Commission report, concluded that this bullet had passed entirely through the president’s neck, from a level over the top of the scapula and lung (and the parietal pleura over the top of the lung), and through the lower throat. 8. Claims that anyone on the commission “moved the wound” are subject to discussion, because Gerald Ford publicly admitted to re-naming the location of the wound, so as “to make things clearer”. The Bethesda autopsy had merely noted that JFK was hit in the upper thorax above the scapula (this is in the soft area at the top of the shoulder) and Ford changed this to “the base of the neck. 9. The Commission report, as amended by Ford, then found the bullet to have passed through the base of the neck, and not to have been in the back. However, Ford’s change is consistent with a bullet hit in the shoulder at the C6 vertebral body, where the HSCA and the photograph placed the wound on the basis of X-damage of the vertebrae and tiny lead fragments in that location. The neck formally begins (and thorax ends) at the level of C7, the first cervical vertebral body above the thorax, and thus the original autopsy report is technically in error (Figs 20.11A to C). The missile wound to the head 1. The wound to the back of the head is described by the Bethesda autopsy as being a laceration measuring 15 × 6 mm, situated to the right and slightly above the external occipital protuberance. In the underlying bone is a corresponding wound through the skull showing beveling (a cone-shaped widening) of the margins of the bone when viewed from the interior of the skull. 2. The large, irregularly shaped defect in the right side of the head (chiefly to the parietal bone, but also involving the temporal and occipital regions) is described as being about 13 cm (5 inches) wide at the largest diameter. 3. Three fragments of skull bone were received as separate specimens, roughly corresponding to the dimensions of the large defect. In the largest of the fragments is a portion of the perimeter of a roughly circular wound presumably of exit, exhibiting beveling of the exterior of the bone, and measuring about 2.5 to 3.0 cm in diameter. X-rays revealed minute particles of metal in the bone at this margin. 4. Minute fragments of the projectile were found by X-ray along a path from the rear wound to the parietal area defect.

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Part IV: Clinical Forensic Medicine Figures 20.11A to C: (A) Medical drawing of a cross-section of President Kennedy’s neck and chest, showing the trajectory of the projectile from back to throat; (B) Photograph depicting the posterior head wound of President Kennedy; (C) Diagram showing the trajectory of the missile through President Kennedy’s skull

Later Government Investigations33,36 Ramsey Clark Panel Analysis (1968) At the request of The Honorable Ramsey Clark, Attorney General of the United States, four physicians (hereafter sometimes referred to as The Panel) met in Washington, DC and reviewed the original autopsy records, photos, and X-rays, as well as clothing, films, motion pictures, and bullet fragments. They also reviewed and discussed the Warren Commission report and presented the following conclusions: Examination of the clothing and of the photographs and X- rays taken at autopsy reveal that President Kennedy was struck by two bullets fired from above and behind him, one of which traversed the base of the neck on the right side without striking bone and the other of which entered the skull from behind and exploded its right side. The photographs and X-rays discussed herein support the abovequoted portions of the original Autopsy Report and the above-quoted medical conclusions of the Warren Commission Report. Major differences with, and support of, conclusions in the Bethesda autopsy and Warren Report: • The Clark report places the head bullet wound 100 mm (4 inches) above the reported occipital protuberance wound of the Bethesda report. This is important, because it is consistent with a high angle rear entry wound to the skull. • The Clark report places the back wound squarely in the neck above the scapula and passing through the throat, passing over the TOP of the right lung, in keeping with the Bethesda conclusions. However, this finding is bolstered by additional findings of metallic fragments along the higher bullet trail. Rockefeller Commission Analysis (1975) The five-member Rockefeller Commission, investigation was limited to the movements of the President’s body associated with the head wound that killed the President.” The Commission examined the films, the autopsy report, the autopsy photographs and X-rays, President Kennedy’s clothing and back brace, the bullet and bullet fragments recovered, the 1968 Clark Panel report, and other materials. The five panel members came to the unanimous conclusion that President Kennedy was struck by only two bullets, both of which were fired from the rear, including one that struck the back of the head. Three of the physicians reported that the backward and leftward motion of the President’s upper body following the head shot was caused by a “violent straightening and stiffening of the entire body as a result of a seizure-like neuromuscular reaction to major damage inflicted to nerve centres in the brain.” HSCA Analysis (1979) The United States House of Representatives Select Committee on Assassinations (HSCA) contained a forensic panel which undertook the unique task of reviewing original autopsy photographs and X-rays and interviewed autopsy personnel, as to their authenticity. The Panel and HCSA then went on to make medical conclusions based on this evidence. The HSCA’s major medical-forensic conclusion was that “President Kennedy was Struck by Two Rifle Shots Fired from Behind Him”. Two questions were put to the experts in HSCA: 1. Could the photographs and X-rays stored in the National Archives be positively identified as being of President Kennedy? 2. Was there any evidence that any of these photographs or X-rays had been altered in any manner? • To determine if the photographs of the autopsy subject were in fact of the President, forensic anthropologists compared the autopsy photographs with antemortem pictures of the President. This comparison was done on the basis of both metric and morphological features, and depicted as that from same person. The anthropologists studied the autopsy X-rays in conjunction with premortem Xrays of the President. A sufficient number of unique anatomic characteristics were present in X-rays taken before and after the President’s death to conclude that the autopsy X-rays were of President Kennedy. • This conclusion was consistent with the findings of a forensic dentist employed by the committee. Since many of the X-rays taken during the course of the autopsy included the President’s teeth, it was possible to determine, using the President’s dental records that the X-rays were of the President. Once the forensic dentist and anthropologists had determined that the autopsy photographs and X-rays were of the President, photographic scientists and radiologists examined the original autopsy photographs, negatives, transparencies, and X-rays for signs of alteration. They concluded there was no evidence of the photographic or radiographic materials

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•

•

Chapter 20: Firearms and Explosive Injuries

•

having been altered. Consequently, the committee determined that the autopsy X-rays and photographs were a valid basis for the conclusions of the committee’s forensic pathology panel. HSCA also concluded that President Kennedy was struck by two, and only two, bullets, each of which entered from the rear. The panel further concluded that the President was struck by one bullet that entered in the upper right of the back and exited from the front of the throat, and one bullet that entered in the right rear of the head near the cowlick area and exited from the right side of the head, toward the front. This second bullet caused a massive wound to the President’s head upon exit. Because this conclusion appeared to be inconsistent with the backward motion of the President’s head in the film, the committee consulted a wound ballistics expert to determine what relationship, if any, exists between the direction from which a bullet strikes the head and subsequent head movement. The expert concluded that nerve damage from a bullet entering the President’s head could have caused his back muscles to tighten which, in turn, could have caused his head to move toward the rear. He demonstrated the phenomenon in a filmed experiment which involved the shooting of goats. However, the HCSA also voiced certain criticisms of the original Bethesda autopsy and handling of evidence from it. These included: 1. The “entrance head wound location was incorrectly described.” 2. The autopsy report was “incomplete”, prepared without reference to the photographs, and was “inaccurate” in a number of areas, including the entry in Kennedy’s back. 3. The “entrance and exit wounds on the back and front neck were not localised with reference to fixed body landmarks and to each other”. These inconsistencies in the original autopsy report resulting in confusion and demanded further investigation and expert analysis of autopsy reports and autopsy material analysis further with discussion etc., though solved direction of firing, the cause of death of President JF Kennedy ultimately, things lead to the evolution of conceptual record in forensic literatures such as Kennedy Phenomena, Single Bullet Theory and Souvenir bullet for ever.

Figs 20.12: Characteristics of shotgun (smooth bore firearm) wounds at various ranges

Figs 20.13: Magnified view of shotgun wounds at 1 yard, 1-2 yards, 2-6 yards and more than 12 yards respectively (left to right)

wound of entry resembles that of firing done at a greater range (beyond 90 cm), e.g. a victim fired at close range, the shots being hit through a wooden partition or window panel, etc.9,16 Explanation – The shots/pellets which are bunched at a close range when strike the primary target (wooden partition

intervening between firearm and victim) the leading shot gets slowed and hit by the after coming shots causing them to veer off or rebound in a wide pattern, just as the billiard balls do when hit with cue ball at the back, and produce wounds over a wider area on the secondary target (i.e., victim). This constitutes billiard ball ricochet effect (Fig. 20.14A). However, this effect

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Part IV: Clinical Forensic Medicine

Fig. 20.14A: Billiard ball ricochet effect at close range of firing16 (Note the bunched shots at primary target (a1)

Fig. 20.14B: No Billiard ball ricochet effect as range of firing increases16 (Note the spreadout shots at primary target (b1)

Figs 20.15A to C: Wound of entry by shotgun (smooth bore firearm) at an approximate range of firing: (A) Contact shot range; note the ‘imprint’/‘copy’ or recoil abrasion of unused barrel, which is pinkish due to carbon monoxide in discharge gases, (B) Fire arm wound: Entrance wound of a shot gun at 2-3 m rage (Courtesy: Dr SC Mestri, Professor and HOD, Forensic Medicine, JSS Medical College, Mysore, Karnataka), (C) 4 m

will not be true as the range of firing increase for the simple reason that the shots are already spread widely (Fig. 20.13B).

• For a Spread Area is 75 cm = Range of firing will be 3 m, etc.

Medicolegal importance—Difficulty in assessing the range of firing.

Exit wound — It occurs only when the shot passes right through and out of the body; the wound will show features like:9,12-16 • Margins everted. • No soiling, singeing, etc. • May be multiple as each pellet or groups of pellets might pass out independently. Usually shotgun pellets do not exit from the body, except: a. Contact shot wound b. Tangential wound where some of the pellets have a very short track through the body and c. Thin parts of the body like neck, extremities etc.16,20

Estimation of Range of Firing by Examining Wound of Entry A rough estimation of range of firing is always possible by examining the wound of entry (and the clothing worn at the time). Principle—As the range of firing increases, the spread area of pellets also increases in a regular manner. Thus, for a cylindrical barrel (non-choked) gun:9,16

For Ranges up to 3 m Range multiplied by 3½ roughly gives the spread area diameter in cm. i.e. Range (r) × 3½ = Spread area (A) Range (r) = Spread area (A)/3½ = A × 2/7 m For Ranges beyond 3 m Roughly the spread area is 25 cm per 1 m range. Thus • For a Spread Area is 25 cm = Range of firing will be 1 m • For a Spread Area is 50 cm = Range of firing will be 2 m 292

AUTOPSY EXAMINATION OF CASES OF FIREARM FATALITIES External autopsy examination — comprises of two parts: • Examination of clothing • Examination of the wounds. Examination of Clothing Purpose of examination of clothing is to establish range of firing, whether it is wound of entry or exit and also sometimes to locate the bullet.9-16,20 Procedure — Clothing is to be removed layer by layer. List all layers and note their condition, any stains, holes, etc. in each

Further examinations by FSL — The clothes collected and examined as above are then dried up in the shade. They are then preserved carefully in clean brown paper envelopes, bags, etc. and sent to forensic science laboratory (FSL) for further examination, to detect the presence of blood, any other biological fluid stains and gunpowder residues.12-16,40-41 Photographing the clothes — Clothes with bullet holes or tracks should be photographed with a scale placed nearby. Infrared photography may be useful in detecting the soot deposits on dark or black coloured garments.20 Examination of the Wounds Bullet wounds must be described with great care for both wound of entry and wound of exit. The various steps include, wound location, and wound description. There may be requirement for excision and preservation of external wound for sending to FSL.9,16,20 Wound location — This is done for both wound of entry as well as wound of exit in relation to top of head, the unshod heel, body midline and certain fixed anatomical landmarks. Wound description — Describe both entry and exit wounds noting the site, size, shape and other details (vide supra). Excise the wound for further microscopic examination — cut the wound with 2.5 cm. healthy skin around it and a minimum of 5 mm. thickness beneath. This portion of tissue is then put in rectified spirit, labeled and sent to FSL9,16,20 Internal Autopsy Examination Apart from routine examination internally the most important thing comprises of study track taken by bullet9,16,20—Best method is by taking a radiograph. However, method of study by insertion of a probe is though used restrictedly, a better procedure is by dissection. Box 20.1 highlights autopsy examination of case of fire arm fatality in the form of a checklist briefly. 1. Role of radiography/X-rays in gunshot wounds:49-53 In gunshot wound cases X-rays should "always" be performed to answer following questions: • Is the projectile present? • If present, where is the projectile located? • If the projectile exited, are projectile fragments present and where are they located? • What type of ammunition or weapon was used? • What was the path of the projectile? Problems to be aware of: • The last few inches of a.22 rimfire ammunition wound track may have no associated hemorrhage. • In a partial exit wound and occasionally in a "shored" exit wound the projectile is in the body despite the presence of an exit wound. • With partial metal jacketed bullets the lead core may exit leaving the jacket (with its ballistically important rifling marks) in the body. Sometimes the opposite occurs. Alternatively the jacket and core may separate in the body and neither exit. Projectiles may be retained in clothing.

• Components of some projectiles are poorly radio-opaque on routine X-ray, e.g. Aluminium jacket, plastic tip, plastic shotshell wadding. • Projectiles may embolise. • Projectiles may ricochet within the body off bones, most commonly the inner table of the skull. • The spread of shotgun pellets in the body seen on Xray cannot be used to determine range of fire because of the billiard-ball effect. • In contact shotgun wounds to the head, all but a few pellets may exit. • Exact projectile calibre cannot be determined due to Xray magnification effects. Diagnostic tips: • “Lead snowstorm” characterizes high velocity centrefire rifle ammunition. Ruled out are full metal-jacketed bullets and lead slugs. • C-shaped or comma-shaped subgaleal lead fragment in head wounds characterises32 or occasionally38 calibre the revolver bullets. • A "pancake" or "disk" with 2 to 4 associated commalike fragments (no "lead snowstorm") characterises the Foster shotgun slug. • The presence of the base screw characterises the Brenneke shotgun slug. 2. Removal, marking and preservation of the bullet — A bullet may be removed at surgery or autopsy, is always removed by a pair of forceps with rubber tips and then dried in shade and preserved in a cardboard box. A mark (initials) of the doctor collecting it may be done at the base or tip of the bullet but never on the body. This is to avoid any damage to rifle markings. 3. If the bullet is lodged in the bone — Cut the bone segment where the bullet may be lodged. 4. Kronlein shot—This is a condition wherein a large portion of brain is thrown out (herniated) of the exit wound but still intact/attached to the wound.9,16

Chapter 20: Firearms and Explosive Injuries

item. Record the number and location of bullet holes. Assign a number to each one and describe them in relation to distance from collar, pockets, etc. Due to creases in clothing, a single bullet can produce more than a single hole. Preferably with a magnifying hand lens try to find out if the fibers of clothes are turned inwards or outwards.9,16,20

GUNPOWDER RESIDUES TESTS There are specific types of tests which could indicate whether the person examined was contaminated with "blowback" residues of gun powder, from having recently fired a weapon.9,16,20,43-47 Such residues are typically removed from the subject by swabbing the back of the index finger, thumb and the web spaces/areas of the hand with a moistened cotton swab containing a solution of five per cent nitric acid. Limitations: However, the value of such an examination is questionable since barium and antimony are also found in nature, as well as in a variety of common products, and it possible that the subject being examined might have come in contact with such sources other than firing a gun. Thus most of these tests are inconclusive and are with ambiguity demands the need of additional forensic evidences in confirming the suspect's guilt.4347 Some of the routinely performed gun powder residue tests are enumerated and discussed. • Dermal nitrate test • Harrison and gilroy test • Neutron activation analysis (NAA) • Image analysis of gunshot residue (IA GSR) • Sodium rhodizonate test Dermal nitrate test—It is a test for gunpowder particles on the hands of the assailant.

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Part IV: Clinical Forensic Medicine

Box 20.1: Checklist for autopsy in firearm deaths 1. 2. 3. 4.

Take an X-ray of the deceased prior to removing the clothing. Recover primer residues from hands by acid (10% nitric) moistened swab or adhesive tape. Examine hands for trace evidence, soot and propellant grains, and blood splatter. Examine and remove the clothing without cutting. Use dissecting microscope to examine clothing defects and wounds for soot and propellant. 5. Examine the body, photograph the wounds if appropriate, and correlate with clothing. Take repeat photographs of the body after cleaning the body and describe the wounds. Note following while describing the Wounds: • Describe each wound completely, i.e. including the internal wound track revealed by dissection. • Describe wound location relative to (a) body landmarks, (b) body midline and heel or top of the head. • Describe the wound appearance by size, shape, abrasion collar (width and symmetry), soot and propellant (its presence, distribution and dimensions) and wound entry scorching/searing. Incase of shotgun/smooth bored firearm wound describe shotgun pellet pattern. • Describe muzzle end imprint and compare with alleged weapon if available at crime scene/when produced later. • Describe the lodged projectile or exit relative to entrance; describe the general direction of wound track. • Describe any recovered projectile or fragments. Trace the wound tracks and recover the projectiles. Complete the dissection. 6. Try to recover/collect: • Propellant grains from skin surface or wound track. • Projectile, taking care not to scratch the surface metal instrumentation such as a toothed forceps while collecting. Use a rubber tipped forceps/gloved fingers in collection of bullets • Sample shotgun pellets and all wadding if any. • Blood for grouping and blood and tissue for toxicology analysis.

Procedure—Mop the hands of suspected person with gauze soaked in molten paraffin, cool to harden. Then treat its inner surface with diphenyle amine and if it gives blue colour, the test is positive. Fallacies—Test is positive with any nitrogenous substance, like urine, tobacco, etc., on hand. Harrison and Gilroy test—This is a test for certain elements or compounds such as antimony, barium, lead, etc. found in firearm discharge residue. Neutron activation analysis (NAA)—This is a test used for estimation of distance of firing and confirming the hands of those suspected of firing a firearm. The test can detect barium, copper, antimony, etc. from the primer present in the firearm discharge residue, which are activated in a nuclear reactor and then identified by the gamma ray spectrometer.9,16,46 Image analysis of gunshot residue on entry wounds—Newer technique and preliminary study have been reported in literature by image analysis of gunshot residues (GSR). In this method an automated image analysis (IA) technique has been developed to obtain a measure of the amount (i.e. number and area) of gunshot residue (GSR) particles within and around a gunshot wound. Sample preparation and IA procedures were standardised to improve the reproducibility of the IA measurements of GSR. However, preliminary results indicated that the decreasing relationship between firing range and the amount of GSR deposited are non-linear, and that for firing ranges of up to 20 cm the amount of GSR deposited from repeated shots fired from the same distance are highly variable.47 Sodium rhodizonate test—This test is performed to detect the particulate lead deposited on surfaces as a consequence of a firearm discharge. This has been directed at addressing some of the problems that have hitherto compromised the value of this test to forensic science. In particular, the aqueous solutions of sodium rhodizonate are considerably more stable when stored below pH 3. The rhodizonate dianion is then diprotonated, forming rhodizonic acid, and the half-life of the solution increases from about one hour to about ten hours. By ensuring that the 294

area to be examined is pretreated with tartrate buffer so that its pH is adjusted to 2.8 prior to treatment with rhodizonic acid, the formation of a nondiagnostic purple complex, instead of the desired scarlet complex, is avoided. Whereas the scarlet complex changes to a blue-violet complex, upon secondary treatment with 5 per cent HCl, which is diagnostic of the presence of lead, the purple complex decolourises completely under these conditions and thus its formation represents wastage of lead from within the test area and is associated with the fading problem that has previously plagued the test. The fading of the blueviolet complex can be eliminated by removing excess HCl, by means of a hair drier once the colour has fully developed.48 MEDICOLEGAL QUESTIONS ON FIREARM INJURIES In a firearm injury death case, basically certain questions need to be answered for medicolegal purposes. Certain important questions are discussed here.8,9,11-13,16 Kinds of the Firearms A proper examination of wound of entry and knowledge about the classification of firearms (vide supra) can help in deciding the type of firearm used. Range of Firing A proper description of the wound of entry can help in deciding the range of firing for both gunshot and shotgun wounds (vide supra). Direction of Firing It can be decided ideally by radiographic examination (vide supra). However, probing the wound is though allowed, method of autopsy dissection procedure is more reliable. Cause of Death It is usually due to the vital organ injury in the path taken by bullet. Accident, Suicide or Homicide? Death due to injuries from firearms is an important public health problem. As a group, injuries from firearms were the ninth leading cause of death in USA with total number of firearm deaths

In India, the rampant proliferation of illicit small arms combined with poor policing, has eroded human rights, weakened democratic institutions and polarised ethnic, religious, economic and political differences between citizens.64-69 It is difficult for enforcement agencies to keep a check on violence when during elections private armies of politicians carrying illicit firearms roam at large.68 The problem of intimidation by such criminal elements is compounded by the fact that legal firearm ownership is so limited – making it impossible for a private citizen to effectively defend himself/ herself. The statistics related to suicides and firearm accidents in India for the year 1990-199464 is presented in Table 20.6. Certain facts helpful in deciding whether a particular firearm wounds is of accidental/ suicidal and/homicidal origin needs to be discussed at this stage:8-16 Accidental—Wound could be found anywhere on the victim's body. Suicidal—Wound seen is often singular and noticed on the most vital part of the body, which is usually easily accessible to the victim himself/herself, e.g. temple, left side of chest—precordium,

Fig. 20.15D: Suicide by rifle: Note the single disruptive wound in the accessible part neck and gripping the muzzle end of the rifle. The victim is a police constable, by profession and alleged to have committed suicide in a sitting posture holding the butt of the rifle firmly against the tree trunk and muzzle end under the chin over front of his neck and operated the trigger by the toes of the right foot (Courtesy: Dr Mahabalesh Shetty, Assoc. Professor and Head, Dept of Forensic Medicine, KSHEMA, Derla Katte, Mangalore and Dr Suresh Kumar B Shetty, Assistant Professor, KMC, Mangalore)

Chapter 20: Firearms and Explosive Injuries

increased by 130 per cent, from 16,720 in 1962 to 38,505 in 1994. If these trends continue, firearm-related injuries could become the leading cause of deaths, surpassing injuries due to motor vehicle crashes. As reported, the patterns of overall firearm-related mortality are due to homicide, suicide, unintentional death, deaths occurring during legal intervention, and deaths of undetermined origin. Suicide and homicide are usually responsible for most firearm fatalities; and are accounted for 94 per cent of the total deaths in 1994 in USA.54-58 The fluctuations and overall increase in rates of total firearm-related mortality most closely resembled the pattern of firearm-related homicide. Although suicide rates were high and gradually increasing over time, they varied less than homicide rates. The rates for unintentional death from firearms, deaths during legal intervention, and deaths of undetermined intent are low and generally declined over a period of time recently. Firearm-related mortality affects all demographic groups, but the greatest increases in recent years were among teens 15-19 years of age, young adults aged 20-24, and older adults aged 75 and older. The rates of overall firearm-related mortality for young people aged 15-24 were higher from 1990-1994 than at any other time. For those 15-19, increases in firearm-related homicide, suicide, and unintentional injury deaths were especially great. The increase in firearm-related homicide in this age group occurred among all race-sex groups. For America's elderly, rates of suicide by firearm were particularly high, and increases occurred in all race-sex groups except black females, for whom number of suicides were too small to produce stable rates.59-63 While these data help characterize the magnitude of the problem and identify groups at risk, there are still gaps in our knowledge.

neck (Fig. 20.15D) etc. Also range of firing in a suicidal death is usually at contact shot range, and the victim may leave a suicide note nearby. Weapon used to fire may be held firmly in the hand by the victim, gripped tightly in a cadaveric spasm. It is also observed that a left handed victim will make a firing on the left side of the head. Points enumerated below are observations in suicidal firing deaths as recorded from literature:9, 12-19, 60-61 • The majority of suicides (including gunshot suicides) do not leave any suicide note. • A contact wound creates a presumption of suicide rather than accident. • With rifle and shotgun wounds to the trunk the trajectory may corroborate suicide. With the weapon butt on the ground and the body hunched over it the trajectory is downwards (not upwards). Reaching for the trigger with the right hand rotates the body so that the trajectory is right to left side (vice versa if reaching with the left hand). • Suicide handgun wounds occur primarily in the head (80%), the chest (15%) and abdomen ( 100 kPa (15 psi) is threshold for lung injury, and tympanic membrane (TM) to rupture routinely; however, a recent Israeli case series of 640 civilian victims of terrorist bombings contradicts traditional beliefs about a clear correlation between the presence of TM injury and coincidental organ damage. Of the 137 patients initially diagnosed as of having isolated eardrum perforation who were well enough to be discharged, none later developed manifestations of pulmonary or intestinal blast injury. Furthermore, 18 patients with pulmonary blast injuries had no eardrum perforation.72 INJURIES DUE TO ANTIPERSONNEL LANDMINES Landmines are defined as any “ammunition placed under/on or near the ground or other surface area and designed to be detonate or explode by the presence, proximity or contact of a person or vehicle.” Antipersonnel landmines are small in size and are specifically targeted for human beings on foot. They are difficult to locate or detect and are activated by direct pressure. These mines could be highly destructive and serve their purpose with telling effect. They are mainly used in guerilla war and in addition to causing physical harm. They also serve as a psychological deterrent to advancing combatants.81 Since 1970s the landmine, like the automatic riffle, has become a weapon of choice for many armies and resistance groups around the world. They are readily available from governments and also a vast global network of private arms suppliers. These mines could also be manufactured relatively easily and cheaply.82 The explosion of mines causes hideous mutilation, deaths and devastating injuries. The small antipersonnel mines disable those who traverse their paths. The injury potential of this

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weapon system, in comparison to that of riffle bullets and fragmentation \weapons is primarily focussed on the lower extremities with a fair proportion of those wounded having injuries remote from the legs. The high amputation rate of these injuries poses a psychological problem as well as orthopaedic and rehabilitative ones. Unlike bombs or artillery shells which are designed to explode when they approach or hit their target, these landmines lie dormant until a person, a vehicle or animal triggers their firing mechanism. They are blind weapons that cannot distinguish between the footfall of combatant from that of a noncombatant. They recognise no cease-fire and could go on killing and injuring long after the hostilities have ended.83 This manmade epidemic has been largely unreported in the medical literature until relief workers drew attention to the thousands of limbless victims of antipersonnel mines in Cambodia.81 It is estimated that there are more than 80 million landmines laid in 65 countries worldwide, some recently and others from conflicts of the past. Together they kill or maim about 150 people a week.83-86 In recent past, landmines were injuring large numbers of people each year in Cambodia. Burma, Mozambique, Ethiopia, Somalia, Iraq, Nicaragua, Angola, SriLanka and many other countries.81-86 As landmines could cause injuries even long after the conflicts are over, medical professionals who are likely to encounter these injuries should have a detailed knowledge and skill in treating such injuries. Pattern of Injury Victims of antipersonnel mines present recognizable patterns of injury. These injuries were categorised according to the patterns described by Coupland and Korver of the International Committee of the Red Cross.87 Each pattern carries its own implications for the surgeon and the patients long-term disability.

Pattern 1 The victim triggeres buried mines by stepping on the device. They usually have a traumatic amputation of part of the lower limb, with less severe injuries elsewhere: mud, grass. Fragments of mine, boot and the remains of the foot were blown upwards into the leg, genitals, buttocks and the contralateral are causing secondary infection. These injuries are the most severe as there is close contact between the device and the foot, when it explodes. Pattern 2 The pattern of wounding is more random and consists of multiple shrapnel wounds from the mines triggered near the victim. Pattern 3 The mine explodes while being handled resulting in injury to the hands and face. Eye injury is sustained from fragments, mud or sand thrown up by the explosion; many victims lose one or both eyes. Type of Injury to Foot Types of injuries to foot are graded in to four grades and they are presented in the form of a line drawing (Fig. 20.19A) and discussed individually:

Grade 1 Injury The injury occurs through the fore foot. There is no damage to the ankle and subtalar joints. The resulting disability is minimal. This type of injury is uncommon. Amputation can be carried

out through the metatarsal bones giving the patient a useful stump.

Grade 2 Injury The injury takes place through the distal row of tarsal bones and is accompanied by damage to the long flexor tendons on the dorsal aspect of the foot. The ankle and subtalar joints, calcaneum and the heel pad are intact. An amputation at this level will result in a viable stump, but on weight bearing the stump goes into plantar flexion as a result of which it becomes difficult to fit a prosthesis. These victims invariably end up with a below-knee amputation. Grade 3 Injury The injury occurs through the calcaneum with complete destruction of the heel pad. They require a below knee amputation. Grade 4 Injury This is the most common and most severe injury where the entire foot is blown off above the ankle joint. It is her unfortunate that this is the commonest injury seen. Treatment is a below knee amputation. Pathological Aspects of Limb Injury Severe limb injury or traumatic amputation produces different levels of tissue damage within the limb due to the variable resilience to injury of skin, fat and muscle. The most striking example is the extreme form of compartment syndrome produced within the leg by antipersonnel mines. This aspect of tissue damage at different levels in the leg caused by the blast of antipersonnel mines should be remembered by all surgeons treating such injuries and the correct level of surgical amputation should be selected to avoid complications (Fig. 20.19B). The three objectives of primary amputation for mine injuries of the foot. In order of priority are: • To excise dead and contaminated tissue and to remove accessible foreign bodies. • To be able to perform delayed primary suture • To leave a stump that is acceptable for fitting prosthesis. The victims of antipersonnel mines are disabled for life. The majority are disabled as a result of traumatic amputation of the lower limb, while a smaller number suffer disability as

Chapter 20: Firearms and Explosive Injuries

Fig. 20.19A: Classification of foot injuries (Grades I to IV)

Fig. 20.19B: Diagram showing: (1) How an injury confined to foot, is associated with damage to proximal compartmental muscle. (2) Explosive injury with traumatic amputation of lower leg. (3) How the extent of proximal damage to leg be hidden when the skin is returned to position

a result of traumatic amputation of the hand, loss of vision or both. Rehabilitation of victims of various mine explosions (Fig. 20.20) should begin as early as possible. This should include physical exercise to the uninvolved muscles and joints and more importantly psychological rehabilitation. Victims of mines suffer tremendous psychological trauma and may take years to regain confidence. Therefore, the aspect of psychological rehabilitation should not be neglected in the overall management of these victims of landmines. Prevention of Antipersonnel Mine Injuries (Figs 20.21 and 20.22) • Public awareness: The medical profession should document the mental and physical suffering experienced by victims of land mines. They should also ensure that the public is made aware of the suffering caused by this man made epidemic. The community living in regions of conflict should also be informed of dangerous areas that are probably laid with mines and best avoided. • Mine survey and eradication: Casualties should be reduced by clearing and destroying the mines that have been already laid. However, complete mine clearing is an expensive, dangerous and perhaps an impossible task as observed in Falklands, Afghanistan and more recently in Kuwait. • Ban on the use of antipersonnel mines: A campaign for the ban of these indiscriminate weapons has already been started by two medical organisations in the United States, namely, Physicians for Human Rights and Human Rights Watch. EMERGENCY MANAGEMENT OPTIONS Follow your hospital and regional disaster plan. Expect an upsidedown triage, with the most severely injured arrive after the less injured, who typically bypass EMS triage and go directly to the closest hospitals. Double the first hour's casualties for a rough prediction of the total first wave of casualties. Mass Casualties Predictor76-80 To predict the total number of casualties your hospital can expect, double the number of casualties the hospital receives in the first hour. Total expected casualties = (No. of casualties arriving in 1-hr window) × 2. 301

Part IV: Clinical Forensic Medicine Figs 20.20A to H: Different types of explosives: (A) Landmine explosion, (B) Jeep blown up by landmine, (C) Anti tank mines, (D) Claymore mines, (E) Antipersonnel mines, (F) Mortar shell, (G) Hand grenades, (H) Mortar shells (Courtesy: Dr G Gunetilleke, Consultant Surgeon, Sri Jayawardenepura General Hospital, Nugglgoda, Sri Lanka)

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Chapter 20: Firearms and Explosive Injuries Figs 20.21A to H: Blast injuries: (A) Shrapnel injury to chin, (B) Shrapnel injury to eye, (C) Bilateral traumatic amputations, (D) Blast injury to both lower limbs, (E) Antipersonnel injury to foot, (F) Child injured by mines, (G) Below knee amputation stump, (H) Danger signs anticipating mines planted (Courtesy: Dr G Gunetilleke, Consultant Surgeon, Sri Jayawardenepura General Hospital, Nugglgoda, Sri Lanka)

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Part IV: Clinical Forensic Medicine Figs 20.22A to D: Types of antipersonnel injuries to foot by landmines: (A) Antipersonnel injury to foot – Grade I, (B) Antipersonnel injury to foot – Grade II, (C) Antipersonnel injury to foot – Grade III, (D) Antipersonnel injury to foot – Grade IV (Courtesy: Dr G Gunetilleke, Consultant Surgeon, Sri Jayawardenepura General Hospital, Nugglgoda, Sri Lanka)

Obtain and record details about the nature of the explosion, potential toxic exposures and environmental hazards, and casualty location from police, fire, EMS, ICS commander, regional EMA, health department, and reliable news sources. If structural collapse occurs, expect increased severity and delayed arrival of casualties. When trying to determine how many casualties a hospital can expect after a mass-casualty event, it is important to remember that casualties present quickly and that approximately half of all casualties will arrive at the hospital within a one-hour window. This one-hour window begins when the first casualty arrives at the hospital. The total expected number of casualties will be an estimate. There are many factors that may affect the accuracy of this prediction, including transportation difficulties and delays, security issues that may hinder access to victims, and multiple explosions or secondary effects of explosion (such as a building collapse). PATTERNS OF HOSPITAL USE In the confusion that often follows a mass-casualty event, managing a hospital can be challenging. Historically, masscasualty events show patterns of hospital use. Public health professionals and hospital administrators can use this information to handle resource and staffing issues during a mass-casualty event. Within ninety minutes following an event, 50 to 80 per cent of the acute casualties will likely arrive at the closest medical facilities. Other hospitals outside the area usually receive few or no casualties. The less-injured casualties often leave the scene 304

under their own power and go to the nearest hospital. As a result: • They are not triaged at the scene by emergency medical services (EMS). • They may arrive to the hospital before the most injured. • On average, it takes 3-6 hours for casualties to be treated in the emergency department (ED) before they are admitted to the hospital or released.80 MEDICAL MANAGEMENT OPTIONS Blast injuries are not confined to the battlefield. They should be considered for any victim exposed to an explosive force. Clinical signs of blast-related abdominal injuries may be silent initially until signs of acute abdomen or sepsis come forward. Standard penetrating and blunt trauma to any body surface are the most common injuries seen among survivors. Primary blast lung and blast abdomen are associated with a high mortality rate. Blast lung is the most common fatal injury among initial survivors. Blast lung presents soon after exposure. It can be confirmed by finding a butterfly pattern on chest Xray. Prophylactic chest tubes (thoracostomy) are recommended when general anesthesia and/or air transport are likely. Auditory system injuries and concussions are easily overlooked. The symptoms of mild traumatic brain injury and post-traumatic stress disorder can be identical. Isolated tympanic membrane rupture is not a marker of morbidity; however, traumatic amputation of any limb is a marker for multi-system injuries. Air embolism is common, and can present as stroke, myocardial infarction, acute abdomen, blindness, deafness,

REFERENCES 1. Mary Bellis. History of Firearms; Retrieved on October 27, 2007, http://inventors.about.com/od/militaryhistoryinventions /a/firearms.htm 2. Historical Aspect, Retrieved on October 10, 2007, http:// library.med.utah.edu/WebPath/TUTORIAL/GUNS/GUNHIST.html 3. Ragsdale BD. Gunshot wounds: a historical perspective. Milit Med 1984;149:301-15. 4. Forensic Medicine Lecture Notes, Dundee University, Retrieved on: October 27th, 2007, http://www.dundee.ac.uk/ forensicmedicine/notes/gunshot.pdf 5. Anatomy of Firearms, Retrieved on October 26, 2007: http:// l i b r a r y. m e d . u t a h . e d u / We b Pa t h / T U T O R I A L / G U N S / GUNANAT.html 6. Wikipedia the free encyclopedia, Retrieved on October 19, 2007, http://en.wikipedia.org/wiki/Ballistics 7. Fackler ML. Civilian gunshot wounds and ballistics: dispelling the myths. Emerg Med Clin North Am 1998;16:17-28. 8. Chndran MR (Ed), Guharaj PV. Forensic Medicine. Orient Longman: Chennai, 2003. 9. Rao NG. Forensic Pathology (3rd edn). House of Research Publication Aid: Manipal, 2003. 10. Krishnan MKR. Handbook of Forensic Medicine and Toxicology. Kothari Books: Hyderabad, 1992. 11. Mukharjee JB. Forensic Medicine and Toxicology. Arnold: Calcutta, 2001. 12. Nandy A. Principles of Forensic Medicine (1st edn) (Reprint). New Central Books: Calcutta, 2004. 13. Parikh CK. Parikh's Medical Jurisprudence and Toxicology for Classrooms and Courtrooms (6th edn). CBS, Publishers and Distributors, New Delhi, Reprinted 2007. 14. DiMaio VJM. Gunshot Wounds. Practical Aspects of Firearms, Ballistics and Forensic Techniques. C P C Press Boca Ranton, Fl, 2004. 15. Knight B. Forensic Pathology. Arnold: London, 2004. 16. Werner U Spitz (Ed). Medicolegal Investigation of Death— Guidelines for the Application of Pathology to Crime Investigation (3rd edn), by Charles C Thomas, Illinois, USA, 1993. 17. Dikshit PC. HWV Cox Medical Jurisprudence and Toxicology, Lexis Nexis Butterworth's, New Delhi, 2002. 18. Dogra TD, Rudra A (Eds). Lyon's Medical Jurisprudence and Toxicology (11th edn). Delhi Law House: New Delhi, 2005. 19. Mathiharan K, Patnaik A (Eds). Modi's Medical Jurisprudence and Toxicology (23rd edn). Lexis Nexis Butterworth's, New Delhi, 2005. 20. Payne-James, Busuttil A, Smock C. Forensic Medicine, Greenwich Medical Media, London, 2002. 21. Belkin M. Wound ballistics. Prog Surg 1998;16:7-24. 22. Bartlett CS. Clinical update: gunshot wound ballistics. Clin Orthop 2003;(408):28-57. 23. Perdekamp MG, Vennemann B, Mattern D, Serr A, Pollak A. Tissue defect at the gunshot entrance wound: what happens to the skin? Int J Legal Med 2005;119:217-22.

24. Denton JS, Segovia A, Filkins JA. Practical pathology of gunshot wounds. Arch Pathol Lab Med 2006;130:1283-9. 25. DiMaio VJ, Zumwalt RE. Rifle wounds from high-velocity, centrefire hunting ammunition. J Forensic Sci; 1977;22: 132-40. 26. Lee I, Kosko B, Anderson WF. Modeling Gunshot Bruises in Soft Body Armor with an Adaptive Fuzzy System. Systems, Man and Cybernetics, Part B, IEEE Transactions on Volume 35, Issue: 2005;6:1374-90. 27. Businessman Shot and Robbed in Geetha Colony, East Delhi, Indian Express, Express News Service New Delhi, March 26, 1999. 28. Simmons GT. Findings in Gunshot Wounds from Tandem Projectiles, J Forensic Sci. 1997;42(4):678-81. 29. Frangible Bullets, Retrieved on: November 05th, 2007: http:// www.frangiblebullets.com/ 30. Wikipedia, the Free Encyclopedia, Frangible bullet, Retrieved on November 05th, 2007. http://en.wikipedia.org/wiki/Frangible 31. Dum dum Bullet, Retrieved on November 05, 2007, http:// www.firstworldwar.com/atoz/dumdum.htm 32. Wikipedia, the Free Encyclopedia, Retrieved on October 19, 2007: http://en.wikipedia.org/wiki/Ballistics 33. Wikipedia the free encyclopedia, Terminal Ballistics, Retrieved on October 27, 2007, http://en.wikipedia.org/wiki/Terminal_ballistics 34. Wikipedia, the Free Encyclopedia, John F. Kennedy Autopsy, Retrieved on: October 19, 2007, http://en.wikipedia.org/wiki/ John_F._Kennedy_autopsy 35. Nelson CL, Winston DC. A new type of shotgun ammunition produces unique wound characteristics. J Forensic Sci 2007;52:195-8. 36. Rutty GN, Boyce P, Robinson CE, Jeffery AJ, Morgan B. The role of computed tomography in terminal ballistic analysis. Int J Legal Med 2007. 37. Geurin PF. Shotgun Wounds. J Forensic Sci 1960;5:294-99. 38. Ordog GJ, Wasserberger J, Balasubramaniam S. Shotgun wound ballistics, J Trauma 1988;28(5):624-31. 39. Patnaik AK, Mathiharan K (Ed). Modi’s Medical Jurisprudence and Toxicology, (24th edn). Butturworth, 2006. 40. RW NG. Forensic Ballistics, 3rd edn. HR Publication: Manipal. India 2003. 41. Jayson PJ (Author), Roger B (Ed), Tracey C (Ed). Encyclopedia of Forensic and Legal Medicine. Elsevier Acadmic Press, 2005. 42. Hussain Z, Shah MM, Afridi HK, Arif M. Homicide Death by Firearms in Peshawar; An Autopsy study. J Ayub Medical College, Abbotabad, 2006;18(1). 43. Zeichner A, Eldar B, Glattstein B, Koffman A, Tamiri T, Muller D. Vacuum Collection of Gunpowder Residues from Clothing Worn by Shooting Suspects, and their Analysis by GC/TEA, IMS, and GC/MS; J Forensic Sci 2003;48(5). 44. Gunpowder Residue: Retrieved on: November 08, 2007: http:/ /www.patrickcrusade.org/crime_scene_ reconstruction.htm 45. Gunpowder Residue: Retrieved on: November 08, 2007: http:/ /www.ez-entertainment.net/features/blake_ gunpowder.htm 46. Krishnan SS. Detection of gunshot residue on the hands by neutron activation analysis and atomic absorption analysis. J Forensic Sci 1974a;19:789-97. 47. Brown H, Cauchi DM, Holden JL, Wrobel H, Cordner S. Image analysis of gunshot residue on entry wounds. I-The technique and preliminary study. Forensic Sci Int. 1999;100(3):163-77. 48. Tugcu H, Yorulmaz C, Karslioglu Y, Uner HB, Koc S, Ozdemir C, Ozaslan A, Celasun B. Image analysis as an adjunct to sodium rhodizonate test in the evaluation of gunshot residues: an experimental study. Am J Forensic Med Pathol 2006; 27:296-9. 49. Folio L, McHugh C, Hoffman MJ. The even-number guide and imaging ballistic injuries. Radiol Technol 2007;78:197-203. 50. Conradi SE. New Aluminum-Jacketed Ammunition: The Case of the "Invisible" Jacket. Am J Forensic Med Pathol 1982;3:153-5. 51. DeMuth WE, Nicholas GG, Munger BL. Buckshot wounds. J Trauma 1976;18:53-7.

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spinal cord injury, or claudication. Hyperbaric oxygen therapy may be effective in some cases. Compartment syndrome, rhabdomyolysis, and acute renal failure are associated with structural collapse, prolonged extrication, severe burns, and some poisonings. Consider the possibility of exposure to inhaled toxins and poisonings (e.g. carbon monoxide, CN, MetHgb) in both industrial and criminal explosions. Wounds can be grossly contaminated. Consider delayed primary closure and assess tetanus status. Ensure close followup of wounds, head injuries, eye, ear, and stress-related complaints. Communications and instructions may need to be written because of tinnitus and sudden temporary or permanent deafness.

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52. DiMaio VJ, Dana SE, Taylor WE, Ondrusek J. Use of scanning electron microscopy and energy dispersive X-ray analysis (SEMEDXA). In Identification of Foreign Material on Bullets. J Forensic Sci 1987;32:38-47. 53. Fischbeck HJ, Ryan SR, Snow CC. Detection of bullet residue in bone using proton-induced X-ray emission (PIXE). J Forensic Sci 1986;31:79-85. 54. National Centre for Injury Prevention and Control, Fatal Firearm Injuries in the United States, 1962-1994, Violence Surveillance Summary Series, No. 3, September 07, 2006. 55. Centres for Disease Control. Rates of homicide, suicide, and firearm-related death among children-26 industrialised countries. MMWR 1997;46:101-5. 56. Centres for Disease Control. National Vital Statistics Reports, USA 2004;52:21. 57. Centres for Disease Control. Surveillance for fatal and nonfatal firearm-related injuries—United States, 1993-1998. MMWR 2001;50(SS-2):1-34. 58. Freed LH, Vernick JS, Hargarten SW. Prevention of firearm-related injuries and deaths among youth. A product-oriented approach. Pediatr Clin North Am 1998;45:427-38. 59. Kohlmeier RE, Mc Mahan CA, DiMaio VJM. Suicide by firearms. Am J Forensic Med Pathol 2001;22:337-40. 60. Cohle SD, Pickelman J, Connolly JT, Bauserman SC. Suicide by air rifle and shotgun. J Forensic Sci 1987;32:1113-7. 61. Zahid H, Mian MS, Hakim Khan Afridi, Muhammad Arif. Homicidal Deaths by Firearms. In Peshawar: An Autopsy Study. J Ayub Med Coll, Abbottabad; 2006;18(1). 62. Luchini D, Di Paolo M, Morabito G, Gabbrielli M. Case report of a homicide by a shotgun loaded with unusual ammunition. Am J Forensic Med Pathol 2003;24(2):198-201. 63. United States Central Intelligence Agency (CIA), The World Factbook 2002, India: www.cia.gov/cia/publications/factbook/. 64. United Nations, International Study on Firearm Regulation, August 1999 update, India: www.uncjin.org/Statistics/firearms. 65. International Action Network on Small Arms (IANSA), "South and Central Asia": http://www.iansa.org/regions/scasia/scasia.htm. 66. National report of India on the Implementation of the United Nations' Small Arms and Light Weapons Programme of Action, 2002, submitted to the UN Department of Disarmament Affairs: http://disarmament.un.org/cab/salw-nationalreports.html. 67. Graduate Institute of International Studies, Small Arms Survey 2003: Development Denied, Oxford: Oxford University Press, 2003;59-60;112. 68. Williams James Arputharaj, Chamila Thushani Hemmathagama and Saradha Nanayakkara, A Comparative Study of Small Arms Legislation in Bangladesh, India, Nepal, Pakistan and Sri Lanka, Colombo, Sri Lanka: South Asia Partnership (SAP) International, July 2003. 69. Thompson N. Devashish. "Small Arms in India and the Human Costs of Lingering Conflicts", in Abdel-Fatau Musah and Niobe Thompson, Eds., Over a Barrel: Light Weapons and Human Rights in the Commonwealth , London and New Delhi: Commonwealth Human Rights Initiative (CHRI), November, 1999;35-64.

70. Source: BBC News Online: Retrieved on November 17th, 2007: http://news.bbc.co.uk/1/hi/uk/4072434.stm 71. Rao NG. Practical Forensic Medicine (3rd edn). Jaypee Brothers Medical Publishers, 2007. 72. Eric Lavonas, Andre Pennardt, Blast Injuries, e-Medicine. Jan 17, 2006, Retrieved on November 17, 2007, Source: http:// www.emedicine.com/emerg/topic63.htm 73. Arnold JL, Halpern P, Tsai MC, Smithline H. Mass casualty terrorist bombings: a comparison of outcomes by bombing type. Ann Emerg Med 2004;43(2):263-73. 74. Marshal TK. Death from Explosive Devices. Med Sci Law 1976;16:235-9. 75. RM Walsh, JP Pracy, AM Huggon, MJ Gleeson. Bomb blast injuries to the ear: the London Bridge incident series, Journal of Accident and Emergency Medicine, 1995;12(3): 194-8. 76. Centres for Disease Control and Prevention (CDC), Emergency Preparedness and Response (2006). Blast lung injury: an overview for prehospital care providers. Source: http://www.bt.cdc.gov/ masstrauma/blastlunginjury_prehospital.asp. 77. Centres for Disease Control and Prevention (CDC), Emergency Preparedness and Response. (2005a). Blast Lung Injury: What Clinicians Need to Know. Source: http://www.bt.cdc.gov/ masstrauma/blastlunginjury.asp. 78. Centres for Disease Control and Prevention (CDC), Emergency Preparedness and Response. (2005b). Brain Injuries and Mass Casualty Events: Information for Clinicians. Source: http:// www.bt.cdc.gov/masstrauma/braininjuriespro.asp. 79. Centres for Disease Control and Prevention (CDC), Emergency Preparedness and Response. (2003a). Explosions and Blast Injuries: A Primer for Clinicians. Retrieved from http:// www.bt.cdc.gov/masstrauma/explosions.asp. 80. Centres for Disease Control and Prevention (CDC), Emergency Preparedness and Response. (2003b). Mass Casualties Predictor. Retrieved from http://www.bt.cdc.gov/masstrauma/predictor.asp. 81. Andersson N, Palha de Sousa C, Paredes S. Social cost of land mines in four countries: Afghanistan, Bosnia, Cambodia, and Mozambique. British Medical Journal 1995;311:718-21. 82. Ascherio A, Biellik R, Epstein A, Snetro G, Gloyd S, et al. Deaths and injuries caused by land mines in Mozambique. Lancet 1995;346:721. 83. Asia Watch, Physicians for Human Rights. Land Mines in Cambodia: The Coward's War. New York: Human Rights Watch: 131, 1991. 84. Cobey JC, Stover E, Fine J. Civilian injuries due to war mines. Techniques in Orthopaedics, 1995;10:259-64. 85. Leveaux C. Doctors Should Actively Support Campaign to Ban Landmines. London: UNICEF, 1996. 86. Stover E, Keller AS, Cobey J, Sopheap S. The medical and social consequences of land mines in Cambodia. Journal of the American Medical Association 1994;272:331-6. 87. Coupland RM, Korver A. Injuries from antipersonal mines: the experience of the International Committee of Red Cross; BMJ 14: 303(6816); 1509-12;1991; Erratum in BMJ, 6:304 (6840): 1509;992.

Thermal injury is defined as injury to the body resulting from localised or generalised exposure to extremes of temperature due to various etiological factors. It can be classified as:1-10 1. Hypothermia: – Trench foot – Frostbite 2. Hyperthermia: – Heat cramps – Heat prostration – Heat hyperpyrexia 3. Injury due to heated solid objects 4. Flame burns (dry heat) 5. Scalds (moist heat) 6. Chemical burns 7. Corrosive burns 8. Radiation injury 9. Electrical injury – Electrocution, lightening 10. Frictional heat – Corn, shoe bite, brush burns, rope burns.9 Normally body temperature is said to be 98.6oF (36oC) when measured orally. However, the body temperature may vary from individual to individual, depending on age, time of the day, physical exertion, and so on. Maintenance of normal body temperature is a delicate balance between heat load and heat loss. Heat load is the sum of heat generated by oxidation of metabolic products and heat acquired from the environment around1,6-8 Heat is lost by three mechanisms:6-8 i. Conduction, ii. Radiation, and iii. Evaporation. Heat loss by evaporation has further two more mechanisms.1-3,5,6 • Insensible heat loss – this is due to continued diffusion of water molecules through the skin and respiratory surfaces regardless of the body temperature. • Heat loss by sweating – this is more important. In cold weather, the sweating is essentially zero, while in hot weather it is maximum. HYPOTHERMIA The term hypothermia is used when an individual’s body temperature is below 95°F (35°C). This will occur when the loss of body heat exceeds heat production.2-6,10-13 This has both clinical and forensic aspects, as even in temperate climates in winter, many people suffer and die of hypothermia.14 Effect of hypothermia may commonly involve extremities and other

Chapter 21: Effects of Cold and Heat

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Effects of Cold and Heat

exposed body parts, i.e. face. This condition is further subclassified as: Trench Foot This is due to exposure to cold (5-8oC) coupled with dampness and there will be no tissue freesing. There will be no permanent injury in trench foot. Frostnip and Frostbite This is due to exposure to cold below 2.5-0oC. Here there will be tissue freesing.14 Initially there will be just numbness and tingling, and no actual tissue damage. This is just because the blood vessels supplying the affected tissue constrict. The skin turns white and waxy or gray in colour and mottled, but feels normal to touch. At this phase the cold injury is known as frostnip.14 Frostbite follows then, when no treatment is given at the initial phase of frostnip. Ice crystals are then formed in the skin and deeper tissues, which can exert osmotic force, causing water to move from intercellular space. This results in oedema of tissues (filling up of intercellular spaces with fluid). At the same time there is cellular dehydration and hyperosmolarity. There is also denaturation of proteins and destruction of enzymes. The skin is numb and discoloured; it is purple in most severe cases. On touching the skin, it does not give normal ‘bouncy’ feeling over skin, rather it feels hard like a rock, block of ice or perhaps like a piece of chicken removed from the freezer. Blisters appear which may become haemorrhagic.14 Incidence The most common cause is exposure to low temperature.2 The term exposure usually means a considerable element of hypothermia. Frost bite commonly occurs in soldiers at winter warfare hiding in the trenches or in a shipwreck in Antarctic waters, etc. Many deaths in mountaineers, hill workers, swimmers and other sportsmen are due to exposure to low temperature. Another group that may suffer exposure to cold, include drunken people, who may collapse or lie down to sleep after too much alcohol and become hypothermic, especially since alcohol causes vasodilatation of the skin, increasing heat loss. Accidental hypothermia occurs among individuals who are lost while hiking or skiing, individuals immersed in ice cold water,2 etc., in places such as higher altitudes of Himalayas, North Bihar, Uttar Pradesh, Kashmir, etc. In marine disasters, hypothermia may be as common a cause of death as drowning or may cause terminal drowning in survivors who can swim or who are clinging to wreckage. Here death may occur within a couple of minutes from sheer heat loss.14 307

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According to Bernard Knight, among the civilian life most of the deaths from hypothermia are seen among old people and in children.1,14 In some old people, hypothermia may be linked with strange psychiatric condition, in which they hide themselves in some corners, in cupboards, or under piles of furniture or other house hold goods. Often they are found nude, making their death suspicious of criminal victimisation.14 However, this so called ‘hide-and-die syndrome’ is though well known, it is not clear whether victim first become hypothermic and then confused, or whether they are already confused, so take off their clothing or hide in a cold place, and thus become hypothermic.14

• Reduction of heart rate and respiration. • Impairment of tissue respiration due to failure of dissociation of oxygen from hemoglobin, resulting in tissue anoxia. • Lowering of body metabolism. • Slowing of body enzymatic process. • Fall of body temperature resulting in cessation of vital functions. • Vascular response of the body for excessive cold includesVasoconstriction of superficial blood vessels resulting in numbness of skin which creates great discomfort resulting in removal of the garments and is known as paradoxical undressing.6,9,15

Factors Modifying Effects of Cold • Age – adults are able to bear cold better than very young and old. Children have a high body surface-to-weight ratio and lose heat rapidly. In some cases of deliberate neglect or careless family circumstances, infants may be left in unheated rooms in winter and suffer hypothermia.1,2,14 • Duration of exposure – the longer the duration, the more severe are the effects due to evaporation of body heat. • Bodily condition – fatigue, exhaustion, intoxi-cation and starvation hasten the effects of cold. • Thyroid deficiency – degree of thyroid deficiency, even clinical myxoedema, which predisposes to low body temperature, may predispose to hypothermia.2,14 • Drugs/ Medications – taking of phenothiazine drugs also predisposes towards hypothermia.14

Paradoxical Undressing Victims of hypothemia often exhibit altered states of judgement, which is know in mountaneering circles as being “cold stupid”. One common but especially bizarre behaviour of hypothermia victims is a conudrum known as ‘paradoxical undressing’.

Pathophysiology of Cold When a healthy person is exposed to extreme cold, following changes may occur and they are10-14 (Fig. 21.1):

Fig. 21.1: Pathophysiology of hypothermia

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Pathophysiology What exactly happens in paradoxical undressing is discussed below in detail. To understand the mystery of why hypothermia victims exhibit paradoxical undressing, we need to know something regarding how the body attempts to protect itself when stressed by the cold. As the body becomes colder, it shunts blood away from the extremities and into the warm core in order to protect vital organs. This is why the feet and hands will often become cold first. Shunting of blood to the core and away from extremities is accomplished through vasoconstriction of peripheral circulation. This allows the outer portions of the body to become better at insulating the core, since it is losing less heat to the outside world.

What Causes Paradoxical Undressing?15 Vasoconstriction occurs when the smooth muscles within the vasculature contract. This effort requires a steady input of energy in the form of glucose from the body’s energy stores. However, due to a lack of blood now travelling to these muscles, they eventually exhaust. As the muscles of the constricted blood vessels run out of energy, they fatigue, relax, and open up. This is known as vasodilatation. With vasodilatation of the blood vessels, an infusion of warm blood from the core of the body rushes into the peripheral extremities. This causes the hypothermia victim to feel overly warm and to start shedding layers of clothing, contrary to the reality that their body temperature is continuing to drop. The victim’s warm blood rushing from their core, coupled with the removal of warm clothing, causes their body temperature to fall even faster. This serves to hasten death from hypothermia and results in another case of paradoxical undressing. Mountaineers with hypothermia have been known to push aside warm clothing and resist rescuers’ efforts to warm them. It is interesting to note that there are no known hypothermia victims who have reached the stage of paradoxical undressing and sur vived without outside intervention. • Paralysis of vasomotor control of the blood vessels results in thrombosis, capillary dilation and stasis of blood and tissue necrosis. This is called frostbite. • Damage to capillary endothelium resulting in increase in capillary permeability, transudation and oedema.

Incidence Frost bite commonly occurs in soldiers at winter warfare hiding in the trenches or in a shipwreck in antarctic waters, etc. Causes • Vasospasm • Paralysis of vasomotor control of blood vessels. Clinical Findings • Skin will be icecold, showing erythematous patches on distal and exposed parts such as ear, nose, fingers and toes. • Generalised muscular stiffness. • Feeble pulse and low heart rate with low blood pressure. • Depressed reflexes. • Lethargy, feels heavy, drowsiness (due to cerebral anemia). • Stupor, delirium, coma and death gradually due to reduction in oxygen supply to tissue, due to its inability of dissociation from oxyhaemoglobin. Treatment • Gradual restoration of body warmth by putting the victim on warm bed, hot water fomentation, hot coffee or tea and stimulants like—digitalis, alcohol, strychnine, etc. orally. • Warm saline may also be given intravenously. Postmortem Findings • Skin—pale with irregular dark red patches on exposed parts. • Brain—congested with ventricles filled with serum. • Heart—full of blood on both sides. • Pancreas—microscopic examination may reveal fat necrosis. Medicolegal Importance • Suicide by exposing to cold is unlikely. • Most of the deaths by exposing to cold are: – Accidental: As observed in alcoholics, who fall asleep even in snow, or a person lost in snow drifts, etc. – Homicidal: As observed in getting rid of unwanted newborn babies or elderly people, etc. by leaving them exposed to cold weather. – ‘Paradoxical undressing’ and ‘Hide-and-die syndrome’ (Refer above) – Both of these can create suspicion of sexual offence on the victim, especially if the victim is a female. HYPERTHERMIA (HYPERPYREXIA) Hyperthermia is an acute condition which occurs when the body produces or absorbs more heat than it can dissipate. It is usually due to excessive exposure to heat. The heat-regulating mechanisms of the body eventually become overwhelmed and unable to effectively deal with the heat, and body temperature climbs uncontrollably. This is a medical emergency that requires immediate medical attention. 16-21 In its advanced state hyperthermia is referred to as heat stroke or sunstroke, Heat stroke may come on suddenly, but usually follows a lessthreatening condition commonly referred to as heat exhaustion or heat prostration. Progression Body temperatures above 40°C (104°F) are life-threatening. This compares to normal body temperature of 36-37°C (97-98°F).

At 41°C (106°F), brain death begins, and at 45°C (113°F) death is nearly certain. Internal temperatures above 50°C (122°F) will cause rigidity in the muscles and certainly, immediate death.17 Causes Trauma and death from hyperthermia or heat is due to the exposure to heat, derived from:1-9 • Natural source such as the heat derived from the sun • Artificial source such as industrial furnaces, huge baking ovens, etc. • Poorly ventilated or closed rooms or a factory wherein the temperature is high and air is moist. Three conditions may result due to high environmental temperature: • Heat cramps—no rise in body temperature • Heat prostration—subnormal body temperature • Heat hyperpyrexia—rectal temperature above 41 degrees.

Chapter 21: Effects of Cold and Heat

Frost Bite (Chilblain, Trench foot, Immersion foot) Frost bite is a syndrome complex comprising of local tissue necrosis.2-8,13

Predisposing Factors Following factors are considered predisposing to the effects of hyperthermia: • Malnourishment • Overexertion • Fatigue • Chronic alcoholism, hunger, lack of sleep, etc. • Mental depression. Pathophysiology of Hyperthermia Effects of hyperthermia may vary from heat cramps, simple exhaustion or transient fainting to profound comatose condition with respiratory and cardiac failure resulting in death of the victim. The various pathological events are presented in the Figure 21.2A6 and the signs and symptoms, treatment are discussed in detail.6,16,17 One of the body’s most important methods of temperature regulation is through perspiration. This process draws heat from inside, allowing it to be carried off by radiation or convection. Evaporation of the sweat causes further cooling, since this endothermic process draws yet more heat from the body. Initially the victim will likely be sweating profusely. This results in body becoming sufficiently dehydrated. With this, production of sweat and avenue of heat reduction through sweating, is arrested. Thus, when the body is no longer capable of sweating, core temperature begins to rise swiftly. Signs and Symptoms Heat prostration/heat exhaustion is characterised by mental confusion, muscle cramps, and often nausea or vomiting. With continued exposure to ambient heat, temperature may rise into the 39 to 40°C range (103 to 104°F), and lead to full-blown heat stroke. Victims may become confused, may become hostile, often experience headache, and may seem intoxicated. Blood pressure may drop significantly from dehydration, leading to a possible fainting or dizziness, especially if the victim stands suddenly. Heart rate and respiration rate will increase (tachycardia and tachypnoea) as blood pressure drops and the heart attempts to supply enough oxygen to the body. The skin will become red as blood vessels dilate in an attempt to increase heat dissipation. The decrease in blood pressure will cause blood vessels to contract as heat stroke progresses, resulting in a pale or bluish skin colour. Complaints of feeling hot may be followed by chills and trembling, as is the case in fever. Some victims, especially young children, may suffer convulsions. Acute dehydration such as that accompanying heat stroke can produce

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nausea and vomiting; temporary blindness may also be observed. Eventually, as body organs begin to fail, unconsciousness and coma will result. Given below is the summary of signs and symptoms: Clinical Manifestations Exposure to high temperature produces several effects, which can be studied under following three headings, namely heat cramps, heat exhaustion and heat stroke:6-8, 16-17

Heat Cramps The victim here complains of severe painful spasms in the voluntary muscles of the body due to excessive perspiration and loss of body electrolytes (following strenuous work in a hot atmosphere). The mortality rate in this is almost nil or negligible. Heat Exhaustion (Heat Collapse, Heat Syncope, Heat Prostration) Heat exhaustion is chiefly because of the effect of the heat on the circulatory system and characterised by6: • Prostration • Peripheral vascular collapse • Pallor (due to poor venous return) • Hypotension (due to poor venous return) • Flushing of the face, throbbing temples, scanty perspiration • Collapse The patient usually recovers and mortality is very rare. Heat Stroke (Heat Hyperpyrexia, Sunstroke, Systemic Hyperthermia, Thermic Fever) Heat stroke is due to the impairment of heat regulation mechanism in the body, especially resulting in death of the victim due to the paralysis of medullary centres. The syndrome complex may present in two forms: • An acute form with sudden onset without any prodromal symptoms. • A gradual onset form with definite prodromal symptoms. Prodromal symptoms These include headache, nausea, vomiting, dizziness, weakness in legs, excessive desire to micturate, etc. 310

Manifestations of the syndrome Various manifestations of the syndrome are: • Sudden unconsciousness and falling or dropping down of the victim to the ground (called heat stroke). • Findings in the face—it will be flushed; pupils dilated initially and become constricted (pinpoint pupil) in later stage, conjunctiva is congested. • Findings in the skin—it will be hot and dry, with no sweating. • Cardiovascular system—pulse will be full, bounding and rapid. • Respiratory system—breathing will be stertorous and rapid. • Body temperature—43°C or more (heat hyperpyrexia) • Central nervous system—the victim will be presenting with delirium and convulsions. The death is due to paralysis of heat regulatory centre in medulla (hypothalamus). Treatment

First Aid Heat stroke is a medical emergency requiring hospitalisation, and the local emergency system should be activated as soon as possible. The body temperature must be lowered immediately. Both passive and active cooling is helpful. Passive Cooling The victim should be moved to a cool area (indoors, or at least in the shade) and clothing removed to promote heat loss (passive cooling). Active Cooling • The person is bathed in cool water, a hyperthermia vest can be applied, or the person may be wrapped in a cool wet towel. • Cold compresses to the torso, head, neck, and groin will help cool the victim. A fan may be used to aid in the evaporation of water (evaporative method). • Use of ice and very cold water may lead to hypothermia; hence they should be used only when there are means to monitor the victim’s temperature continuously.

Hydration • Hydration is of paramount importance in cooling the victim. This is achieved by drinking water (Oral rehydration). Commercial isotonic drinks may be used as a substitute. Alcohol and caffeine should be avoided due to their diuretic properties. Some authorities oppose the administration of any fluids, except by emergency personnel. Intravenous hydration (via a drip) is necessary if the victim is confused, unconscious, or unable to tolerate oral fluids. • The victim’s condition should be reassessed and stabilised by trained medical personnel. • The victim’s heart rate and breathing should be monitored, and CPR may be necessary if the victim goes into cardiac arrest. • The victim should be placed into the recovery position to ensure that their airway remain open. Prevention • Avoid overheating and dehydration. • Light, loose-fitting clothing will allow perspiration to evaporate. • Wide-brimmed hats in bright colour keep the sun from warming the head and neck; vents on a hat will allow perspiration to cool the head. • Avoid strenuous exercise during daylight hours in hot weather. • Be aware of humidity in presence of direct sunlight which cause the heat index to be 10°C (18°F) hotter than the atmospheric temperature shown in thermometer.16,17 • Persons in hot weather need to drink plenty of liquids to replace fluids lost by sweating. Thirst is not a reliable sign indicating that a person needs fluids. A better indicator is the colour of urine. A dark yellow colour indicates dehydration. While alcohol, tea, and coffee are all diuretics, they will replace more water than they remove (with the exception of concentrated alcohol). However, pure water is still preferred. Susceptible Populations While anyone can be affected by hyperthermia, some populations are especially susceptible to heat illness and injury. Heat illness most seriously affects the poor, urban-dwellers, young children, those with chronic physical and mental illnesses, substance abusers, the elderly, and people who engage in excessive physical activity under harsh conditions.16 Medicolegal Importance • Hyperthermia can be created artificially by drugs or medical devices. This is known as thermotherapy or therapy by inducing hyperthermia. Hyperthermia can be intentionally produced for medical purposes. • It may be used as a cancer treatment to kill or weaken tumor cells, with negligible effect on healthy cells. • Malignant hyperthermia is a rare complication of some types of general anaesthesia.

• Death due to hyperthermia is usually accidental, as observed in dry humid places. It may rarely be suicidal or homicidal. • Unfavourable working conditions at industrial unit leading to hyperthermia in an employee can attract provisions of Workmen’s Compensation Act. • Murder by administration of mixture of belladonna or atropine and possibly cocaine simulating heat apoplexy is also reported. • In cases of sunstroke patient may pass into stage of suspended animation and hence resuscitative measures should be offered before pronouncement of death. Table 21.1 summarizes the salient points on mechanisms, clinical features, treatment complications and medicolegal aspects of hyperthermia17-22

Chapter 21: Effects of Cold and Heat

• Immersing a victim into a bathtub of cold water (immersion method) is a recognised method of cooling. This method requires the effort of 4-5 persons and the victim should be monitored carefully during the treatment process. This should be avoided in an unconscious victim; if there is no alternative, the victim’s head must be held above water.

Postmortem Findings No findings can be considered as characteristic. However, following are observed: • Postmortem caloricity, i.e. the body temperature is high even after the death. The normal postmortem cooling of the dead body is not observed. • Eyes – pitting and sinking of eyeballs is usually seen, which could mimic the evolution of eyeballs. • Rigor mortis sets in early and passes off early. • Postmortem stains are marked on account of a greater fluidity of blood. • Putrefaction is rapid. • Degeneration of cerebral cortex, cerebellum and basal ganglia are common. • Congestion of the entire viscera is common. Note – Blood may be preserved for detection of alcohol as over indulgence in alcohol often precipitates fatal attacks. SCALDS1-9 Scalds are trauma resulting from the application of moist heat commonly involving only superficial layers of the skin. Causes of Moist Heat Moist heat is generated in the following forms: • Hot water or oil or any liquid at or near boiling point • Superheated industrial steam. Clinical Features Usually the scalded area presents a swollen, vesicated and bleached appearance. Since the clothing worn cools faster, the scalding effect is usually less prominent in clothed areas. Likewise, the temperature of the moist heat cools gradually as it disperses all around from the point of contact producing maximum damage at point of commencement. However, clinically scalding is classified into three degrees: i. Erythema, ii. Vesication, and iii. Necrosis of dermis. Erythema: This is the reddening of the skin which appears at once as the moist heat is applied (Fig. 21.2B). Vesication: Also called blister formation is chiefly due to increased capillary permeability, and this needs a few minutes to develop. Usually blisters are surrounded by a bright red zone of inflammation and present as a swelling. On removing a blister, it open leaves a pink coloured raw area. 311

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Table 21.1: Summary of mechanisms, clinical features, management and medicolegal Importance and complications of hyperthermia Hyperthermic disorders

Mechanisms

HEAT STROKE

Failure of thermoregulatory systems resulting in severe hyperthermia and multisystem damage. Usually accompanied by electrolyte imbalance and cardiac arrhythmias. There are often seizures, neurological damage, DIC, rhabdomyolysis, renal and hepatic failure

• Often rapid in onset • May be preceded by headache, nausea, weakness, myalgia • High fever 105-107°F (40.6-46.7°C) • Dilated pupils • Hot dry skin • Lack of sweating (classic) • Confusion, ataxia and/or loss of consciousness • Fast thready pulse • Hypotension • Heart failure

• Support airway, breathing, and circulation • Shift to cooler place and hospitalize • Provide aggressive cooling • I/V fluid and electrolyte therapy • Support vital functions

• Highly lethal • 20 per cent or more have residual neurological damage • Patients with exertional heatstroke may continue to sweat

HEAT EXHAUSTION

Water and/or salt depletion from excessive sweating that is inadequately replaced

• Insidious or sudden onset • Weakness, lightheadedness, syncope, sweating, nausea • Low-grade fever • Pale, cool, clammy skin • Sweating • Thready pulse • Low BP • There may be ataxia and confusion

• Patient should lie down in a cool area • Fluid and salt should be replenished. Slightly salty or sports drinks can be given in sips over 2-4 hours. IV’s needed if very ill or unable to take oral fluids

• May be similar in presentation to insulin shock, alcohol/drug abuse/withdrawal, or hypovolemia from occult blood loss • Usually benign, but may progress to heat stroke

Hypovolaemia causes weakness and collapse

Clinical features

Medicolegal importance and complications

HEAT CRAMPS

Heat cramps are deep and painful spasms in the most actively used muscles and are a direct result of salt depletion

• The affected muscles harden and become tender. Spasms of the upper or lower extremities can be debilitating, and abdominal muscle spasms may mimic an acute abdomen

• Eating salted foods and drinking enough fluid in the heat can usually prevent heat cramps

• Patients should move to a cool area and replenish salt and fluids.

SUNBURN

Sunburn is not considered a heat disorder but occurs with overexposure to ultraviolet (UV) sunrays

• The skin becomes tender and reddened several hours after exposure and may blister and later peel

• Limiting skin exposure to direct sunlight, (midday) and the application of a sunscreen are the best ways to prevent sunburn • Aspirin, and cool moist compresses, relieve discomfort • Corticosteroids may be needed in severe sunburns

• Para-aminobenzoic acid (PABA) and/or benzophenone with sun protection factor (SPF) should be applied prior to sun exposure • Opaque zinc oxide and titanium oxide creams can block sunrays.

Necrosis of dermis: This results when deeper layers of skin are involved. On healing, scar is much thinner and it produces less contraction and disfigurement. Medicolegal Importance • Usually scalds are accidental due to splashing or pouring of fluids while cooking or bathing, etc. 312

Management

• • • • •

The accident is common in children or in elderly. Boiling water may be thrown with malicious intent. Deliberate scalding by hot water is common in child abuse. However, suicide and homicide by scalding is extremely rare. Scalding could be either antemortem or postmortem. Table 21.2 gives the differences between them. At times scalding and dry heat burns may have to be differentiated from each other. Table 21.3 gives these differences.

Fig. 21.2B: Scalds of the left thigh Table 21.2: Differences between antemortem and postmortem scald Characteristics

Antemortem scalds

Postmortem scalds

Line of redness Vesicle Content of vesicles Infection

+ve +ve Albuminous +ve

–ve –ve Gas/Air –ve

DEATH DUE TO FIRE (DEATH DUE TO BURNS) In India there are several thousands of deaths occurring due to fire or burns.1-9 Unfortunately a vast majority of these cases occur in the home and are due to smoking, defective electrical wiring, defective kerosene stove bursts, attempted suicides by self-immolation, homicidal burns of young women by the husband or in-laws (Dowry deaths/bride burning23,24), etc.

Factors Modifying Effect of Burns6-7 • Intensity of heat applied—higher the intensity the more severe will be the effects • Duration of exposure—more the duration, the more severe will be the effects • Depth of burn—The depth of burn injuries is particularly important especially if the burn is causing decreased oxygen supply to the end digits of the body or difficulties with chest expansion and breathing. Depending on skin and its morphology (Fig. 21.3) burns could be of three types: superficial burns, partial thickness burns (mid-dermal and deep-dermal) and full-thickness burns.

Chapter 21: Effects of Cold and Heat

• Scarring is usually more with burns due to dry heat. It would be present in cases involving dermis. Burns involving only epidermis will heal without scar formation. • Keloid formation is more common with corrosive burns. • Curling’s ulcer—is a rare sequel of severe burns, seen in the duodenum. It is due to tissue hypoxia and capillary endothelial damage (Named after Dr TB Curling who reported it in 1842).

Superficial Burns These burns are usually red, moist and very painful. The outermost layer of the skin is involved (the epidermis) and there may be blisters present. Healing generally occurs within 7-10 days with minimal or no scarring. Partial Thickness Burns • Mid-dermal: The outermost layer of skin is lost, as well as parts of the dermis (the next layer of skin). The burn is pink in colour, with small white patches. The skin still blanches on pressure and is painful. Healing occurs in 7-14 days depending on the degree of skin destruction. Some mild pigmentation or scarring may result.

Definition Deaths due to fire or burns usually result from the application of dry heat to the body.6 Incidence of Burns Incidence of burns could be due to building catching fire, clothes worn catching fire, inflammable liquid fire explosions, industrial furnace burns, etc. Classification of Burns Three different types of classification are accepted1-9 (Table 21.4) and they are: • Dupuytren’s classification • Heba’s classification • Modern classification. Effects of Burns • Usually all the two stages of Modern classification (Table 21.4) may be seen together.

Fig. 21.3: Skin and its morphology presenting the structures in its depth

Table 21.3: Differences between scalds and burns1-9 Characteristics

Scalds

Skin Vesicles Singeing of hair Charring Soot particles in upper respiratory tract Scar

Sodden and bleached Seen all over scalded area Absent Absent Absent Thin

Burns Dry and shrivelled Only seen at burnt area Present Present Present Thick

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Table 21.4: Differences in classification of burns

Degree of damage

Dupuytren’s

Heba’s

Modern

Superficial redness Vesication Destruction of superficial skin Destruction of whole skin Destruction of muscles Complete charring

1st degree 2nd degree 3rd degree 4th degree 5th degree 6th degree

1st degree 1st degree 2nd degree 2nd degree 3rd degree 3rd degree

Superficial Superficial Superficial Deep Deep Deep

• Deep-dermal burns: Here there is deeper dermal destruction. The burn appears white and does not blanched on pressure. The skin is less sensitive and takes a longer period of time of heal, with scarring. Full Thickness Burns Full thickness burns extend deep down into the dermis. The burn is leathery, ranges in colour from white/grey/black and is non-painful. There is loss of sensation and it does not blanch on pressure. Healing occurs from around the edges of the surrounding skin but the process is slow, with scarring and contracture. • Extent of body surface area (BSA)–if the surface area is great, fatality is usual. Thus, for estimating the prognosis and deciding the line of treatment, usually the clinicians adopt

a rule called rule of nines, which helps in estimating fluid loss, shock, etc. Under this, the body is divided into different areas, each representing 9 per cent. When surface area involved is more than 20 per cent the fluid loss is marked, resulting in shock and usually, involvement of 30 to 50 per cent is fatal. Figures 21.4A and B, and Table 21.5 present the idea of estimating the percentage of body surface area involved in burns. Lund and Browder chart for children is useful to calculate body surface area in which age of victim is an additional factor incorporated. ‘Rule of nines’ is used to calculate the body surface area burnt in an adult. This does not apply to infants whose body proportions are different from adults. Recently, computer-based softwares have been introduced with colour coded calculation and instant resuscitation guide (Fig. 21.4C).26

Figs 21.4A and B: (A) Rule of nines (for adults) and (B) Lund-Browder chart (for children) for estimating extent of burns (Relative percentage of body surface area–% BSA) (Courtesy: Artz CP, JA Moncrief: The Treatment of Burns (2nd edn). Philadelphia, WB Saunders Company, 1969)25

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Fig. 21.4C: Sample surface area graphic evaluation (SAGE) software method (Courtesy: Estimating burn area ICU room pearls, Archive of www.icuroom.net Issue)26

Table 21.5: Percentage of body surface area involved in burns (Rule of nine)

Anatomic areas Head and neck Right upper limb (Arm) Left upper limb (Arm) Right lower limb (leg) (Front and back) Left lower limb (leg) (Front and back) Anterior trunk (Thorox and abdomen) Posterior trunk (Thorox and abdomen) External genitalia/perineum

Percentage of body surface 09 09 09 (9+9) (9+9) (9+9) (9+9) 01

• Site of the body—burns of the trunk, lower abdomen, genitalia are fatal • Age of the patient—aged people are more prone to fatality than children and adults • Sex of the patient—sensitive nervous women are more susceptible to fatality than strong women and men. Causes of Death in Burns Death usually occurs either before 48 hours or after 48 hours, hence, the causes can be classified accordingly into two groups.6-7

Death Occurring within Few Hours Victim may die due to shock, coma and asphyxia. Each of these is discussed individually below:

Shock • Primary (neurogenic) due to—fear, severe pain, injury to vital organs leading to death within 24 to 48 hours • Secondary (vascular) due to loss of serum from burnt area— developing depletion of blood volume and hypovolaemic shock, leading to death within 24 to 48 hours. Coma Coma due to congestion of brain and serious effusion into ventricles. Asphyxia Suffocation due to the inhalation of smoke or gasps of combustion. Asphyxia may also be caused by pressure on the chest due to falling roof, beams, walls, etc. when a house is on fire.

Death Occurring within Few Days Victim may die due to inflammation of internal organs, gangrene, exhaustion, septic absorption, toxaemia, hepatorenal syndrome, etc. Each of these is discussed individually: Inflammation of Internal Organs These are inflammation leading to meningitis, peritonitis, pneumonia, bronchitis, pleurisy, enteritis, and Curling’s ulcer in the duodenum. Gangrene Complications connected with the ulcers produced by burn such as gangrene, erysipelas, tetanus, profuse haemorrhage on separation of slough, etc. 315

Part IV: Clinical Forensic Medicine Fig. 21.5: A female victim of self-immolation by pouring kerosene on the body and lighting with matches. Swollen face, lips, singed scalp hairs, burnt eyebrows and eyelids, disfigured completely

Exhaustion Exhaustion due to severe pain and dehydration from loss of fluid. Septic Absorption Septic absorption from excessive suppuration. Suppurative case death may occur by 5 to 6 weeks or even after a longer time. Pseudomonas is most common organism responsible for infection and sepsis in turn. Toxaemia Toxaemia occurs due to absorption of histamine formed as a result of combustion of tissue. Hepatorenal Syndrome In every case of burns of any severity, absorption of altered protein occurs and this in turn leads to cellular damage to liver and kidneys (acute tubular necrosis). Heart may also undergo similar damage.

Fig. 21.6: Entire body of the same victim (as in Fig. 21.5) in pugilistic attitude with 70% of skin burns

Postmortem Appearances of Burns1-9 In any case of burns postmortem signs of burns will be present even if burns are postmortem in nature, but signs of antemortem burns suggest death due to burns.

antemor tem burns skin will show line of redness (hyperemia) which is a sign of vital reaction (Fig. 21.7). • Degloving / destocking may be seen due to cuticular peeling (Fig. 21.8).

External Clothing It should be removed carefully and examined for the presence of kerosene, petrol and other such inflammable and combustible substances. Any other articles Such as keys, metallic rings, ornaments, etc., worn on the body should be removed and preserved. It may be useful in establishing identity. Face Usually distorted, swollen with tongue protruded out (Fig. 21.5). Skin Findings observed vary according to the nature of the substance used to produce burns: • Radiant heat-whitish (Fig. 21.6) • Highly heated solid objects when: – Applied momentarily: Blister and reddening corresponding to the shape and size of the material used. – Prolonged application: Roasting and charring. • Explosions in coal mines or by gun-powder—blackening and tattooing of the parts. • Kerosene oil burns: characteristic odor and sooty blackening of the parts (See Figs 21.5 and 21.6). However, all 316

Hair They undergo a peculiar effect of heat called singeing. The singed hair looks curly and is highly fragile. Cut section shows presence of plenty of vacuoles within microscopically. Pugilistic attitude (Boxer’s attitude, Fencing attitude)— It is a condition wherein the body assumes a rigid position with the limbs flexed and resembles a boxer in defending position3-9 (Fig. 21.9). • Appearance: All the four limbs are flexed with closed fist, body is bent forward and skin is tense, leathery, hard and frequently shows splitting • Causes: Under the effect of heat, the muscle proteins coagulate causing them to become contracted • Medicolegal importance: It could be due to antemortem or postmortem burns, especially if the body is burnt, charred and black. The pugilistic attitude can be mistaken for a pre-death attempt to shield oneself from an attacker.23 Cracks and fissures resembling incised wound may be seen in line with blood vessels exposed through them. Charring of the body depends on degree of postmortem burns or burning of the body after death.

Chapter 21: Effects of Cold and Heat

Fig. 21.7: Line of redness and vital signs of the burns wounds at it margins over the front of the left thigh, suggestive of antemortem burns note—vesication on the inner aspect of the thigh

Fig. 21.9: Pugilistic attitude in a burns victim

Fig. 21.8: Degloving of cuticle of both hands in same victim as in Figure 21.5

Fig. 21.10: Soot particles in the upper respiratory tract

Internal • Skull bones—may be fractured and burst open due to intense heat, along the skull sutures • Brain and meninges – Congested – Blood is usually extravasated imparting a brick red colour on upper surface of dura mater (heat haematoma) – Brain is sometimes shrunken. • Larynx, trachea and bronchial tubes— contain carbon and soot particles (Fig. 21.10) and mucosa is congested with frothy mucous secretions. This is suggestive of antemortem burns due to inhalation of gases resulting in suffocation and asphyxia • Pleura—congested and inflamed with serous effusion • Lungs—congested and oedematous

• Heart—chamber full of blood, cherry red in colour due to inhalation of carbon monoxide • Stomach and intestines—stomach may contain carbon impregnated mucous membrane. It may be red. There may be inflammation and ulceration of Peyer’s patches and solitary glands of intestine. Ulceration may be sometimes found in duodenum known as Curling’s ulcer. This is due to the liberation of some irritating substances in liver which cause thrombosis of small vessels only when victim survives for 7-10 days.3-9 • Spleen—enlarged and softened • Liver—cloudy swellings and necrosis of the cells if death is delayed • Kidneys—show signs of nephritis. Straight tubules are filled with debris of blood cells giving reddish brown marking. 317

Part IV: Clinical Forensic Medicine

Table 21.6: Differences between antemortem and postmortem burns

Characteristics

Antemortem burns

Postmortem burns

Line of redness+vital sign Vesication

Present (See Fig. 21.7) Present and true, contains serous fluid Present Congested Cherry red due to CO Present Present Present

Absent Present but are false, contains PM gases Absent Usually roasted+emits peculiar odour Not so Absent Absent Absent

Reparative process Internal organs Blood Curling’s ulcer Inflamed Payer’s patches Carbon/soot particles in trachea, bronchus

Medicolegal Importance 1. Identification of the deceased—Though identification of the deceased is difficult when the body is completely burnt, following may be helpful: • Metallic objects on the body like rings, bangles, keys, etc. • Sex of the deceased: Prostate and nulli-parous uterus will not get burnt even at very high temperature and could help in sex identity. • Age of the deceased: Usually established by the teeth and ossification of the bones. 2. Whether the burns are antemortem or postmortem? Table 21.6 enumerates these differences. 3. Whether the burns are the cause of death or not? Following two factors confirm burns as cause of death: • Presence of carbonaceous or soot particles in the respiratory tract mixed with mucoid secretions. • Cherry red discolouration of blood due to carboxyhaemoglobin. 4. Whether the burns are suicidal, accidental or homicidal? • Suicidal burns are common among Indian women. They pour kerosene oil and set fire to themselves. Some women stuff clothes inside the mouth also to prevent shouting and being heard by others. • Accidental burns are common among children and elderly people. Accidental kerosene stove bursting is also reported often. • Homicidal burns are quite common in India. The pernicious customs of dowry among certain Hindu castes, sometimes leads to young maidens, being murdered by pouring kerosene and set on fire by husband or in-laws (later claimed to be accidental burns death). This has lead to the concept of dowry deaths or bride burning which has enforced a rule by the Home Ministry of India to involve a panel of two doctors in conducting the postmortem examination of married woman dying of burns or any other reasons within 7 years of marriage or if her age is less than 30 years at the time of death in suspicious circumstances (IPC, Section 304B).24,25 5. Self-inflicted burns for false accusation—these burns are usually seen on accessible parts of the body.6 6. Spontaneous combustion and preternatural combustion— occasionally cases are reported of burns occurring due to the natural gases evolved in the intestine, (inflammable gases such as hydrogen sulfide, methane, etc.) When these gases are passed out per anally in a living person if they get ignited/ 318

come across a flame may lead to burns. Recently all these cases have been turned down considering them as myth.6 7. Dead body of victim may be burnt after death to conceal homicide. Head injury and fatal neck compression are commonly reported methods of homicide. REFERENCES 1. Sukho P (Ed). B Knight’s Forensic Pathology. Arnold, London 2002. 2. Di Maio DJ, Di Maio VJM. Forensic Pathology. CRC Press, USA 2001. 3. Mukharjee JB. Forensic Medicine and Toxicology. Arnold: Kolkata 1:1981. 4. Nandy A. Principles of Forensic Medicine. New Central Books: Kolkata 2000. 5. Parikh CK. Parikh’s Medical Jurisprudence and Toxicology for Classrooms and Courtrooms (6th edn). CBS Publishers and Distributors: New Delhi. Reprinted 2002. 6. Rao NG. Clinical Forensic Medicine (3rd edn). HR Publications, Manipal, India 2003. 7. Chandran MR (Ed). Guharaj’s Forensic Medicine (2nd edn). Orient Longman: Hyderabad 2004. 8. Mathiharan K, Patnaik AK (Eds). Modi’s Medical Jurisprudence and Toxicology (23rd edn). Lexis Nexis Butterworth’s 2005. 9. Werner U. Spit (Ed). Medicolegal Investigation of Death Guidelines for the Application of Pathology to Crime investigation (3rd edn). Charles C Thomas: Illinois, USA 1993. 10. Hypothermia, Retrieved on: August 14, 2007: Source: http:// www.faqs.org/health/Sick-V2/Hypothermia.html. 11. Web Source: Dated: August 14, 2007: Source: http:// www.ncbi.nlm.nih.gov/sites/entrez?cmd = Retrieveanddb = PubMedandlist_uids = 358883 and dopt = AbstractPlus. 12. Jankowski Z. Death from accidental hypothermia. Part I. Principles of Physiology of Thermoregulation, Pathophysiology and Mechanisms of Death from Hypothermia, Arch Med Sadowej Kryminol 2002;52(4):313-22.Links. 13. Aggrawal A. Self Assessment and Review of Forensic Medicine and Toxicology (MCQs with Explanations and Discussions), (1st edn). Peepee Publishers and Distributors: New Delhi, 2006. 14. Bernard Knight, Simpson’s Forensic Medicine (11th edn). Arnold: London 1997. 15. Paradoxical-undressing, Retrieved on: 20 August 2007: Source; http://www.survivaltopics.com/survival/paradoxical-undressing. 16. Rampulla J. Hyperthermia and heat stroke: Heat-related conditions. The health care of homeless persons. Boston Health Care for the Homeless Program 2004;199-204. 17. Web Source: dated: 22 August 2007: http://en.wikipedia.org/wiki/ Hyperthermia. 18. Bouchama A, Knochel JP. Heat stroke. The New England Journal of Medicine 2002;346(25):1978-88.

23. Thermo week, Retrieved on: 30th August 2007, Source: http:/ /www.interfire.org/termoftheweek.asp?term=1660. 24. Chandrachud YV, Manohar VR, Avtar Singh, Ratanlal, Dhirajlal. The Indian Penal Code (Act XLV of 1860), (30th ed), (Thoroughly Revised and Revitalised), Wadhwa and Co. Nagpur, New Delhi, 2004. 25. Artz CP, JA Mencrief: The treatment of Burns (2nd edn), Philadelphia, WB Saunders Company, 1969. 26. Estimating burns area by Surface Area Graphic Evoluction (SAGE) Software method. ICU Room Pearls. Archieves of www.icuroom.net (December 30, 2005).

Chapter 21: Effects of Cold and Heat

19. Centres for Disease Control and Prevention. Heat-related deaths — four states, July-August 2001, United States, 1979-1999. MMWR 2002;51(26):567-70. 20. Centres for Disease Control and Prevention. Heat-related mortality — Chicago, July 1995. MMWR 1995;44(31): 577-9. 21. Curriero FC, Heiner KS, Samet JM, et al. Temperature and mortality in 11 cities of the eastern United States. American Journal of Epidemiology 2002;155(1):80-7. 22. Weisskopf MG, Anderson HA, Foldy S, et al. Heat wave morbidity and mortality, Milwaukee, Wis, 1999 vs. 1995: an improved response? American Journal of Public Health 2002;92(5):830-33.

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22

Electrocution, Lightning and Radiation

Electricity, lightning and radiation are also considered as physical agents that can result in to both nonfatal injuries and death. Recently these are included under environmental emergencies1 and are dealt independently for better understanding of trauma produced. ELECTROCUTION Electrical injuries are relatively common, complex and potentially devastating form of trauma, both in industrial and domestic circumstances. The manifestations and severity of electrical trauma encompass a wide spectrum, ranging from a transient unpleasant sensation due to brief contact with low-intensity household current to instantaneous death and massive injury from high-voltage electrocution/lightning injury. Unlike thermal burns, electrical injuries commonly involve multiple body systems with the potential to pose difficult challenges regarding accurate assessment and proper management.1-2 Thus injury due to electricity may include burns to the skin and deeper tissues, cardiac rhythm disturbances and other associated injuries due to falls and other trauma. The amperage, voltage, type of current (AC vs DC) duration of contact, tissue resistance and current pathway through the body will determine the type and extent of injury. Higher voltage, greater current, longer contact and flow through the heart are associated with worse injury and worse outcome. In general, lightning exposure/ contact may result in the most severe form of electrical injury.2 The passage of substantial electrical current through the tissues can cause skin lesions, organ damage and death. This injury is commonly considered as electrocution injuries. Fatalities are usually accidental, both in domestic and industrial environment.2-13 Electricity energy may be generated spontaneously in nature by lightning or artificially in the form of electric current. Electric current generated artificially are of two types, direct and alternating.4-6,8-13 Direct current (DC) Wherein the current flowing continuously in one direction is less dangerous (200-250 milliamp intensity of direct current is lethal). A high amperage DC (above 4 A) may even cause an arrhythmic heart to revert to sinus rhythm, as in medical defibrillation using defibrillator. Alternating current (AC) Wherein the current shows rapid alteration in direction of flow. Alternating current is more dangerous than direct current (70-80 milliamp intensity of alternating current is lethal). This is because of the “hold on” effect it imparts making the muscles undergo a tetanoid spasm which prevents the victim from releasing the live conductor. It 320

is also much more likely to cause ventricular fibrillations and arrest. In fatal electrocution often three major events may occur (Fig. 22.1), which are a threat to life and are as follows: • The most common is the passage of current across the heart, usually when a hand is brought into contact with live conductor, and the body is opposite to the hand. It has been claimed that the most dangerous is contact with the right hand and exit through feet, as this causes the current to pass obliquely along the axis of heart. The fatal process is cardiac arrhythmia, usually a ventricular fibrillation ending in asystole • Less often, the passage of a current across the chest and abdomen may lead to respiratory paralysis from spasm of intercostal muscles and diaphragm

Fig. 22.1: Pathways of current in electrocution

Effect due to Passage of Electricity Effects of electric current in the human body are of two types:3,5,6,8-13,16 i. Local effects and ii. Constitutional effects.

Local Effects • Burns and blisters: Characteristically these are seen in the skin and referred to as cutaneous electrical mark. A Joule burn is the more popular terminology designated to this, while it is also known as electrical burns or electrical marks (Figs 22.2A and B). Joule burn is an endogenous thermal burn, i.e. it is due to the heat generated within the body during the flow of electric current.16 It differs from exogenous burn, where the burn is caused by sparking; wherein the source of heat is outside the body.6,8,16 If the skin is touching the conductor wire/faulty electrical appliance is moist, it may not show any electrical burns/marks/joule burns; while thick and dry skin will show a well circumscribed electrical burns/ marks.16,17 The lesion is seen as puckering of skin around the edges of the electrical burns without any red line surrounding the burns or reddening of the base at the point of entry of electric current (hands, fingers) (Fig. 22.2C) and point of exit (opposite hand or feet) (Fig. 22.2D). As with many other injuries shape of the object causing electrocution may some times be noticed, constituting patterned electric mark.8 This finding may be helpful in reconstruction of the injury events and giving final opinion on cause of death in an unwitnessed electrocution deaths/ in situation of obscure/ negative autopsy cases. • Contusions and lacerations: The wound may also be lacerated, and punctured with contusions at its margins. The

point of exit of current or the ‘earth’ takes place through the bare sole of the foot. Sole of the foot may turn hard and thick and even be ruptured giving a deep laceration like appearance.11 Singeing of hair and burning of clothes may also be noticed at the location. • Metallisation of electrical marks: When current passes from a metal conductor into the body, a form of electrolysis occurs so that metallic ions are embedded in the skin and even the subcutaneous tissues. This can occur with both AC and DC because of the combination of metallic ions with tissue anions to form metallic salts. These are though invisible to naked eye, may be detected through chemical, histochemical and spectrographic techniques. They persist for few weeks when alive and resist a moderate amount of post mortem change when dead.8,20 Electron microscopy has recently visualised these metallisation as tiny globules of molten metal on the skin at and near electric marks.8,21 • Micropathological skin changes at electrocution site: Basically it is an electrical burn. These local lesions are usually found

Chapter 22: Electrocution, Lightning and Radiation

• Rarely, current passes through the head and neck, usually in circumstances when the head of a worker on overhead power lines comes into contact with conductor. In such instances, there may be a direct effect on the brain stem so that cardiac or respiratory centres are paralysed. It is commonly said that tolerance can be gained to electric shock and the professional electricians often work with live conductors with impunity. It seems more likely that expectation of a shock decreases sensitivity, but only for brief contacts, less than would be required for physiological or structural damage.

Figs 22.2A and B: Firm contact: (A) Electrical marks, (B) Spark burn across air gap

Fig. 22.2C: Joul burn/electrical burns mark/electrical mark: Note: A well circumscribed mark with puckering of skin around but no red line around burns mark/at its base-point of entry, suggestive of point of entry (Courtesy: Dr B Suresh Kumar Shetty, Assoc. Prof. of Forensic Medicine, KMC, Mangalore)

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Fig. 22.2D: Sole of the foot showing lacerated wound due to exit of current

Fig. 22.3: Diagrammatic representation or features of electrocution

in the hands or fingers at the points of entry and exit of electric current, which are more severe and are observed mostly over feet or opposite hands (Fig. 22.3). Following changes are usually observed at these sites microscopically.6,8,17,19-21 — Compression of the horny layer—into homogenous plaque and ironing out of the underlying papillary processes. — Fissures and hollows may appear between the stratum corneum and germinativum. — Basal cells changes—are the surest sign of electrocution and the coalescence of basal cells into a star-shaped or rod-like structure in each group of the rete malphigii occurs. — Charring and vacuolation—in the deeper cells of epidermis and dermis, formed by gas spaces from heated tissue fluids splitting the cells apart. 322

Figs 22.4A and B: (A) Working on power line on an electrical pole; (B) Electrical high voltage flash fire

— Metallisation in the skin – with occasional deposition of fine metallic particles of the conductor substance may also be seen in a few cells.8,20,21 — Epidermal nuclei are pyknotic, elongated and aligned in a parallel or palisading fashion, often referred as “nuclear streaming”. • Flash or spark burns—High tension currents can jump several millimeters across air and cause lesions. It is estimated that in dry air an electric current of 100 kV can jump up to 35 mm. Such high tension currents can produce extremely high temperatures (up to 4000oC), just like the spark plug of petrol engine. This intense heat, which may result from flash of electricity, produces burns (Figs 22.4A and B), which resemble thermal burns over large area, and can cause the keratin of the skin to melt over multiple small areas. This molten keratin over these area fuses into multiple hard brownish nodules on cooling and resembles skin of the crocodile. Thus,

Chapter 22: Electrocution, Lightning and Radiation

the terminology ‘crocodile skin’ (Fig. 22.4C) lesion was coined.3-13,16 Sometimes, multiple lesions (Figs 22.4D and E) are found in the region of excess flexion of a limb where the current has passed across the joints instead of passing around it.

Constitutional Effects Victim may suffer from the constitutional effects which comprise of the following:22-27 • Momentary shock with complete recovery if the current is small. • Get stunned and/may go into suspended animation like state and/suffer from hemiplegia/paraplegia/loss of sight/loss of hearing/loss of speech, etc if alive. • Immediate death when the current flown in is lethal. However, the alternating current with moist clothes, bad health, state of anxiety, etc. may aggravate these effects. Causes of Death As already stated most of the deaths in electrocution are due to ventricular fibrillation (in low voltage current) ending in cardiac arrest. This is caused by passage of current through myocardium, especially in the superficial epicardial layers and possibly across the endocardium. The current has a profound effect directly upon the myocardial syncytium, the possible dislocation of the pace making nodes and conducting system being ill-understood. A recent study of cardiac pathology among the victims of death due to electrocution, reported that the frequency of MFB (myofibre break-up) is maximal histopathologically in cases of electrocution deaths (90%) and the finding of MFB is considered as an ante-mortem change and declared as a distinct finding in all cases electrocution.18 The term myofibre break-up (MFB) includes the following histological patterns19 (Figs 22.5A to C). a. Bundles of distended myocardial cells alternating with hypercontracted cells. In the latter group of cells, there is also widening or rupture (segmentation) of the intercalated discs. Myocardial nuclei in the hyper-contracted cells have a “square” aspect rather than the ovoid morphology seen in the distended myocytes. b. Hyper-contracted myocytes alternated with hyperdistended cells that are often divided by a widened disk. c. Non-eosinophilic bands of hyper-contracted sarcomeres alternating with stretched, often apparently separated sarcomeres. This observation is extremely helpful in establishing cause of death in obscure/negative autopsy cases wherein opinion as to cause of death is difficult for want of gross findings at autopsy examination in spite of positive history of electrocution. Among the other causes of death in electrocution inhibition of respiratory centre (in high voltage), which is though second common cause, is far less common. Here when the current passes through the thoracic cage, it causes the intercostal muscles and diaphragm to go into spasm, or become paralysed. In either case however, respiratory movements are inhibited and a congestive-hypoxic death results. The brain stem is rarely affected in electrocution, when the current enters through the head. Either cardiac arrest or respiratory paralysis can then supervene. Finally, it may also be remembered here that non-electrical causes such as fall/being thrown from height resulting in associated injuries, more often result in fatality in a victim of electrocution.

Figs 22.4C to E: High voltage burns: (C) the leg, involves large area and called crocodile skin lesion (Courtesy: Dr IG Ghosh, Former Prof. and HOD, Forensic Medicine, IG Medical College, Simla), (D) on the trunk, (E) over the right forearm, thighs, etc. (Courtesy: Dr Mitha Prasanna, Former Prof and HOD, Burns and Plastic Surgery Unit, Kasturba Hospital, Manipal)

Medicolegal Aspects • Death by electric current is usually accidental but cases of suicide and homicide have also been recorded.13-17 Bathroom is a common site for electrical tragedies. Accidents, suicides and even homicides occur there because of its vulnerability to electric shock.8 Suicides from electricity have increased recently especially in Germany.14 Though homicide is rare, it is recorded in United States.15 Again in United States, electricity has become a mode of judicial execution.15,16 • Judicial electrocution – death penalty is carried out in the electric chair, in some of the states, namely: Alabama, Florida, Georgia, Kentucky, Nebraska and Tennessee, in the USA (Figs 22.6A to D). The condemned person is strapped to a wooden chair, and one electrode is put on the shaven scalp (in the form of a helmet) and the other on the right lower leg and current is passed with initial burst of 2000-2400 volts, for a short time (seven seconds) of one minute through the body, which makes the person lose consciousness immediately. It is the second surge, of lower intensity of 500-600 volts for a longer duration 323

Part IV: Clinical Forensic Medicine Figs 22.5A to C: Histopathological pictures presenting MFB: (A) Bundles of hyper-contracted myocytes (arrows) alternated with bundles of hyper-distended myocardial cells (trichrome stain 100); (B) Square nucleus expression of contraction (arrow) (H&E 630); (C) Separation of sarcomeres (arrows) in myofibres connected with contracted ones (H&E × 250)18,19

Execution by Electrocution in Electric Chair Electrocution was first introduced in New York in 1888 as a more humane method of execution then hanging. But there have been horrific instances of inmates catching on fire, multiple jolts being needed to kill, and bones being broken by convulsing limbs, etc. In USA the electric chair is an option for those who committed crimes before 1999, when lethal injection became the state’s primary method of execution. Since the US Supreme Court reinstated the death penalty by electrocution in 1976, there have been several inmates executed in the electric chair, most recent being the condemmed murderer in Virginia in July 2006.

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Figs 22.6A to D: Excution by electric chair: (A) Tennessee’s electric chair; (B) The condemned is first strapped to the wooden electric chair. Note one of the electrode fixed to the right lower leg; (C) Showing another criminal executed by electrocution: Note other electrodes fixed to the shaven scalp in the from of a helmet and the electric current is passed; (D) After the excution (Source: http://www.smh.com.au, Sunday Morning Herald, Tennessee, September 12, 2007-5:19PM, Retrieved: 16.5.09)

LIGHTNING Lightning differs only in degrees from ordinary electric currents. A lightning bolt is produced when the charged undersurface of a thundercloud discharges its electrical charge to the ground. Since the under surface of the cloud is usually negatively charged, virtually all discharges are negative. Approximately 5 per cent of the lightning flashes, however, are positive charges. These are most frequent in mountain regions. 1-12 A flash of lightning (Fig. 22.7A) from a thundercloud to the earth can pass direct current of enormous potential (1000 million Volts or more). Along the track of the

current much energy is liberated most of which is converted into heat.12,13,16 Four electrical mechanisms of lightning injury (Figs 22.7B to D) have been described: direct strike, contact, side flash, and ground current.22 Mechanical injury may occur if the person falls or is thrown by muscle contraction.22 Added to these four, is the fifth mechanism of injury by upward streamer such as a flag, banner, bunting, etc. as the cause. 22,23,29-31 These mechanisms are discussed briefly: • Direct strike—The terminology is self explanatory and here the lightning bolt hits the victim directly. • Contact/Conduction through another object—The terminology means the victim making contact with another object which is hit by lightning and thus getting the injuries rather indirectly.22 • A side flash12,22—In a side-flash strike, the bolt of lighting hits an object, such as a tree, and then jumps from the object, striking the individual nearby. In a direct strike or a sideflash strike where the individual is relatively close to the object from which the bolt jumps, the current can spread over the surface of the body, enter it, or follow from both routes. In the majority of cases seen by the autopsy surgeon, the current has both spread over the surface of the body as well as entered. In such cases it is quite common to find the clothing torn, shoes burst, hairs seared (singed), burns on the skin due to metal zipper and other metal objects heated by the lightning, and burns of entrance and exit of

Chapter 22: Electrocution, Lightning and Radiation

(17 seconds to one minute) which actually kills the victim. The process is repeated. After five minutes, a physician checks the heart beat. If the heart is still beating, the voltage is delivered again. The first person to be electrocuted was William Kemmler, in the New York’s Auburn Prison, on August 6th, 1890. Underneath the electrodes the skin temperature may rise as high as 60oC. The temperature of brain in such cases also rises to similar levels. Histopathologically rupture of neuroaxons and blood vessels can be demonstrated in the brain. Right leg goes into cadaveric spasm immediately. Often ejaculation of semen may take place at death. • In cases of electrocution with wet body surface—no positive findings may be present and autopsy in such cases may be an obscure one (refer above cause of death).

Figs 22.7A to E: Lightning and Lightning injuries: (A) Lightning hits beyond a church building, making a severe electrical storm made its way across southern Manitoba, July 1995; (Source: Marc Gallant, www.cbc.ca/.../story/2008/06/20/f-lightning.htm1) (B) Lightning injuries lesions (burns sustained over the trunk at points of lightning entry) (Source: http://pagesperso-orange.fr/dmtmcham/jpeg/trajet.jpg); (C) Torn cloths of lightning victim; (D) Fernlike patterns are classic called as — Arborecent marks/Lichtenberg bodies/Filigree burns etc. (E) Lightning injury over left ear and left side of the face struck by lightning while listening to i-pod music. (Source: http://www.labnol.org/ assets/images/Photograph When Lightning Strikes PeopleList _FEE5/ipodburnears.jpg)

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current. 12,16,17 Rupture of tympanic membrane is not uncommon.12 A lightning victim found on the road with torn clothing, burst shoes, etc and other injuries have many a times been misinterpreted as hit and run victim.8-12 • Ground current—Once the electrical energy that is generated with lightning has flown into the body of a victim, who has been struck by the lightning, it will move towards the ground/ earth and this results in injuries. • Fifth mechanism—This fifth mechanism of lightning injury may aid in the investigation of deaths and injuries when previously described mechanisms of lightning injury cannot be implicated. Thunderclouds can drag charge inside them as well as underneath them. Cloud-to-ground lightning approaches the earth in jagged branched steps about 30-90 meters in length.32 When the tip of any branch gets within a few hundred meters of the ground, the electric field becomes very large, inducing charges to begin at the ground and surge through any object projecting above the ground, including people.32,33 An example for this would be a lighting bolt hitting a tallest crane/ which in turn will let the electricity flow down its metal structure and strike the worker touching it. The injury produced on the victim will be same as if the crane had hit a high-power electrical line, resulting in burns at the entrance and exit points, which are often multiple and severe.12 However, it may be noted here that, not all upward streamers get connected with downward leaders to complete lightning channels. Uman MA, suggests that individuals can be injured by a weak upward streamers34 also, which, may not be connected with downward leaders.30 Darveniza M, adds the facts that these non-discharge currents could vary from 10 to 400 A, “certainly enough to impair body sensors and functions,” but that “the gross physical effects of such currents are likely to be small, because of their relatively small magnitude and because of their short duration”.23 Lightning While in an Automobile/Using Telephone/ I-pod Music System If one is inside a metal vehicle, such as car, bus, truck or even a train, when struck by lightning, the probability of injury is extremely small. 12,22-24 A report on death or injury of an individual while using a telephone and the line, hit by lightning is though quite unusual, cannot be ruled out.25 Another surprising report is on lightning injuries in the ear and the face while listening music in an i-pod (Fig. 22.7E) Cause of Death in Lightning Immediate death from lightning is usually caused by high-voltage direct current.3-12, 22-24 Death in lightning is due to syncope/ cardiopulmonary arrest/electrothermal trauma/paralysis of nervous system. Death may also be delayed in lightning victims and is usually attributed to the complications of burns. If the electrocution is secondary to a close proximity point of impaction, survival of the victim is possible. However, it is a well established fact is that the most of the victims of lightning episode survive.12 Postmortem Features of Lightning Death Includes findings on the body and findings on clothing worn. Body findings are described under external and internal findings.24

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External Ecchymosed burns of all degrees (usually caused by fused metallic substances).

• An arborescent marking is a fern-like injury, is also known as filigree burns or lightning prints, etc. on the skin are pathognomonic of lightning injury. It is a patterned area of transient erythema which appears within an hour of accident and gradually fades within 24 hours. It is reported to be caused by positive discharges over the skin.24 • It is said to occur when a person is stuck by a negative lightning bolt is then hit by a secondary positive flashover from a nearby grounded object. A second possibility is that it represents an entrance point in an individual struck by a positively charged lightning bolt.8,12, 24 A third precedent explanation of the good past is that it is due to deposition of copper on the dermis and also said to be due to staining of tissues by haemoglobin from lysed red cells along the path of electric current.4-13 These are not lesions due to burns (see Figs 22.5A to C). All these explanations, neither of which is exclusive of other, would explain the relative rarity of arborescent lesion in individuals struck by lightning.

Internal • Congested membranes—often with laceration • Intracranial and intracerebral effusion of blood • Patchy hemorrhage on pleura and lung surface • At times, severe disruption may cause widespread petechiae. Findings on the Clothing • Burnt clothes at the site of entry and exit of lightning. Clothing are usually torn, shoes burst. • Fused metallic articles in the vicinity. Medicolegal Aspects Death by lightning is always accidental.24 There is always a thunderstorm in the locality. There may be presence of fused metallic substances in the vicinity, absence of any wound in the body. Evidence of damage caused by lightning in the vicinity, may substantiate the circumstantial evidence in the diagnosis of accidental death by lightning. RADIATION Exposure to radiation can occur through two mechanisms:3,28 The First Mechanism is from a strong radioactive source such as uranium; The Second Mechanism is contamination by dust, debris and fluid containing radioactive material. Factors that Determine Severity of Exposure • Duration of time exposure, • Distance from radioactive source, and • Shielding from radioactive exposure. Types of Radiation Exposure The three types of radiation exposure include alpha, beta and gamma. The most severe exposure is gamma (X-ray radiation). Effects of Radiation In general, radiation exposure does not present with any immediate side effects unless exposure is severe. Most commonly, serious medical problems occur years after the exposure. Acute symptoms include nausea, vomiting and malaise. Severe exposure may present with burns, severe illness and death (beta or gamma). In the modern world people are exposed to radiation from various sources which can be classified as:

IONISING RADIATION (IR) IR can produce radiation injury by tearing the atoms and molecules of a substance and there by damage the body. Thus, when it passes through a living cell, it can damage the cell by tearing apart the chemical make up of the cell. It gets injured badly, loses its ability to function and ultimately killed. Usually cells in tissues which are growing rapidly are highly sensitive to radiation. For example, bone marrow cells in the centre part of a bone are the fastest-growing structures in human body and thus they gets destroyed first, when exposed to ionising radiation. IR can come in the from of electomagnetic waves. IR is usually given off by the sun, X-ray machines and radioactive elements. Sources of IR Injurious to Human Health Humans are exposed to ionising radiation (IR) from a variety of sources. These sources fall into four general categories: • Natural • Intentional • Accidental and • Therapeutic.

Natural Exposure to natural sources of IR account for a very fraction of radiation injuries. Natural sources include sunlight and cosmic radiation. Sunlight includes not only visible light, which has relatively few health effects, and radiation of higher frequency, such as ultraviolet radiation. Just stepping outdoors exposes a person to IR in sunlight. Cosmic rays are similar to sunlight in that they are always present around us. They are not visible, but they do contain ionising radiation. Intentional Exposure Intentional exposure to IR is uncommon, unusual and very rare. It occurs when nuclear weapons (hydrogen and atomic bombs) are used as weapons of war. This has occurred only twice in history, when the United States dropped atomic bombs on Hiroshima and Nagasaki, Japan, at the end of World War II. Many thousands of people were killed or injured by these attacks. They are the only people ever to have been injured by intentional exposure to IR. Accidental Exposure Accidental exposure occurs when a person is exposed to IR by mistake. For example: • Research laboratory spillage: Radioactive elements are sometimes spilled in a research laboratory. Workers in the lab may be exposed to the IR from those elements. • Nuclear reactor accidents: 1945 and 1987, there were 285 nuclear reactor accidents worldwide. More than fifteen hundred people were injured and sixty-four were killed in the se accidents. e.g. Chernobyl Nuclear Reactor accident victims are even today suffering from the after effect. Therapeutic Exposure to IR Occurs during various medical procedures. Radioactive elements and ionising radiation have many valuable applications in diagnosing and treating disorders. But those treatments can have harmful as well as beneficial effects on patients. The rate of radiation injuries due to this cause probably cannot be measured. Many people who may have been injured by a radiation

treatment probably died of the condition for which they were being treated. Medical—Diagnostic and therapeutic doses of radioactive (tracer) elements are given to the patients. Sometimes these are applied by external beam using radioactive cobalt (supervoltage therapy) for the treatment of cancers. Radiation in therapeutic doses is by and large harmless, but skin reactions at the site of supervoltage application are common. This at first presents with depletion and erythema of skin but later may produce blistering and discolouration of skin. Industrial—In various industries especially in watch, drug and chemical analysis radioactive substances are used. War—Nuclear weapons used by superpowers usually produce mechanical trauma, burns and radiation sickness due to ionising radiation Action—The ions produced alter the chemical structure of various enzyme systems. Foetus and child are more susceptible. Hematological changes and disability are more likely with dose above 50 to 100 rads. Hemopo, etic cells, Payer’s patches of small intestine, germinal epithelium of testis and cornea are highly sensitive to it as compared to musculoskeletal tissues.35-40

Chapter 22: Electrocution, Lightning and Radiation

a. Ionising radiation b. Non-ionising radiation, i.e. U-V rays, visible light, infrared rays, microwaves.

Medicolegal Aspect • The doctor who is in charge of the patient’s treatment has to be careful regarding application of supervoltage therapy as patient can sue him or her if the patient can prove negligence on the part of doctor. • Autopsy in cases with amount of radioactivity more than 5 millicuries need extraprecautions like-use of rubber gloves, plastic aprons, spectacles and plastic shoe covers. Burns due to Ultraviolet Rays • These produce erythema and eczematous reaction. REFERENCES 1. Electrocution: Retrieved on: 11th August 2007: Source: http:// h o m e . n y c a p . r r. c o m / c o u n t y / M a s s Pr o t o c o l s / ELECTROCUTION.htm 2. Electrocution: Retrieved on: 11th August 2007: Source: http:// home.nycap.rr.com/county/MassProtocols/table_of_contents.htm 3. Richard Shepherd, Simpson’s Forensic Medicine (12th edn). Publisher: Edward Arnold Publication: 2003. 4. Mathiharan K, Patnaik AK (Eds). Modi’s Medical Jurisprudence and Toxicology (23rd edn). Eastern Book Co., Luknow. 2005. 5. Parikh CK. Parikh’s Medical Jurisprudence and Toxicology for Classrooms and Courtrooms (6th edn). CBS Publishers and Distributors: New Delhi. Reprinted: 2002. 6. Rao NG. Clinical Forensic Medicine (6th edn), HR Publication Aid, Manipal, India, 2003. 7. Werner U Spitz (Ed). Medicolegal Investigation of Death Guidelines for the Application of Pathology to Crime Investigation (3rd edn). Charles C Thomas, Illinois, USA, 1993. 8. Sukho P (Ed). Knight’s Forensic Pathology. Arnold: London, 2007. 9. Guharaj PV. Forensic Medicine. Orient Longman: Chennai, 1985. 10. Mukharjee JB. Forensic Medicine and Toxicology: I, Arnolds: Kolkatta, 1994. 11. Nandy A. Principles of Forensic Medicine. New Central Books, Kolkatta, 2000. 12. Di Maio JD, Di Maio VJM. Forensic Pathology. CRC Press, 2001. 13. Patnaik (Ed). MKR Krishnan’s Handbook of Forensic Medicine and Toxicology. Kothari Books: Hyderabad, 1992. 14. Holder JC. An Unusual Method of Attempted Suicide. Med Leg J 1960;28:41-3. 15. Ornstein FP. Homicide by electrocution. J Forensic Sci 1962;7: 516-7.

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16. Aggrawal A. Self Assessment and Review of Forensic Medicine and Toxicology (1st edn). Peepee Publishers and Distributors (P) Ltd, New Delhi 2007. 17. Camps FE. Interpretation of wounds. Br Med J 1952;2:770-4. 18. Vittorio Fineschi. Steven B. Karch. Stefano D’Errico, Cristoforo Pomara, Irene Riezzo, Emanuela Turillazzi: Cardiac Pathology in death from electrocution. Int J Leg Med 2006;120:79–82. 19. Baroldi G, Silver MD, Parolini M, Pomara C, Turillazzi E, Fineschi V. Myofiber break-up (MFB): a marker of ventricular fibrillation in sudden cardiac death. Int J Cardiol 2005;100:435–41. 20. Marcinkowsky T, Penkowski M. Significance of skin metallisation in the diagnosis of electrocution. Forensic Sc. Int 1980;16:1-5. 21. Torre C, Veretto L. Dermal surface in electric and thermal injuries: observations by SEM. Am J Forensic Med Pathol 1986;7:151-8. 22. Cooper MA, Andrews CJ, Holle RL, Lopez R. Lightning injuries. In Auerbach PS (Ed): Wilderness Medicine: Management of Wilderness and Environmental Emergencies (4th edn). St. Louis, MO: Mosby 2001;73-110. 23. Darveniza M. Electrical aspects of Lightning injury and damage. In Andrews CJ, Cooper A, Darveniza M, Mackerras D (Eds): Lightning Injuries: Electrical, Medical, and Legal Aspects. Boca Raton, FL: CRC Press, 1992;23-37. 24. Eriksson A, Ornehult L. Death by lightning. Am J Forensic Med Pathol 1988;9:295-300. 25. Johnstone BR, Harding DL, Hocking B. Telephone related lightning injury. Med J Aust 1986;144:706-9. 26. Ten Duis HJ, Klasen HJ, Nijsten MWN, et al. Superficial lightning injuries – their “Fractal” shape and origin. Burns 1987;13:1416. 27. Shaw D, York Moore ME. Neuropsychiatric sequelae of lightning strike. Br Med J ii: 1957;1152-64. 28. Internet Source: Dated: 19th June 2003: http://home.nycap. rr.com/ county/MassProtocols/RADIATION% 20INJURIES%20% 20.htm

29. Mary AC. A fifth mechanism of lightning injury. Acad Emerg Med 2002;9(2):172-4. 30. Uman MA. Physics of lightning phenomena. In Andrews CJ, Cooper MA, Darveniza M, Mackerras D (Eds): Lightning Injuries: Electrical, Medical, and Legal Aspects. Boca Raton, FL: CRC Press 1992;6-22. 31. Mackerras D. Protection from lightning. In Andrews CJ, Cooper MA, Darveniza M, Mackerras D (Eds): Lightning Injuries: Electrical, Medical, and Legal Aspects. Boca Raton, FL: CRC Press 1992;14556. 32. Anderson RB, Carte AE. Struck by Lightning. Archimedes. Pretoria, South Africa: Foundation for Education, Science and Technology 1989;31(3):25-9. 33. Krider EP. Physics of Lightning. The Earth’s Electrical Environment, Studies in Geophysics. National Academy Press, Washington, DC 1986;30-40. 34. Krider EP, Ladd CG. Upward Streamers in Lightning Discharges to Mountainous Terrain. Weather 1975;30(3): 77-81. 35. Koenig TR, Wolff D, Mettler FA, et al. Skin injuries from fluoroscopically guided procedures: Part I, characteristics of radiation injury. Am J Roentgenol 2001;177(1):3-11. 36. Koenig TR, Mettler FA, Wagner LK. Skin injuries from fluoroscopically guided procedures: Part 2, review of 73 cases and recommendations for minimising dose delivered to patient. Am J Roentgenol 2001;177(1):13-20. 37. Thomas B Shope, United State Food and Drug Administration. Biomed Imaging Interve J 2007;3(2):e22. 38. Vano E, Arranz L, Sastre JM, et al. Dosimetric and radiation protection considerations based on some cases of patient skin injuries in interventional cardiology. Br J Radiol 1998;71(845):5106. 39. Wanger, et al. Radiation injury. Biomed Imaging Interv J 2007;3(2):e22. 40. Internet Source: Free Health Encyclopedia, http:/www,faqs.org/ health/sickv4/Radiation-Injuries.html Retrieved on May 17, 2009.

Medicolegal aspects of injuries are often not taken heed by treating doctor, which may obviously lead to unnecessary legal litigation. The various ingredients of this major subdivision which the doctor must better be aware of are: • IPC (Indian Penal Code) sections relevant to injuries • Examination of the injured • Complications of injuries • Injuries of medicolegal importance More emphasis is given to the former two subdivisions in the enumerated list as the latter two are already discussed in depth under relevant chapters (see Chapters 16 to 19). IPC SECTIONS RELEVANT TO TRAUMA Injury (Section 44, IPC) Section 44 defines injury.

Definition As per this section, injury is defined as any harm whatsoever illegally caused to any person in body, mind, reputation or property. Explanation Thus, in the legal sense it is clear that injury can be caused by without touching the body. Causing mental agony, damaging the reputation of the person by making false allegation (defamation case), or causing damage/loss of property belonging to another person, etc. are also considered as injuries in law. Hurt (Section 319, IPC) Section 319 defines hurt.

Definition Hurt is defined as causing bodily pain, disease or infirmity to a person. Examples Pulling hairs of another person to cause pain, transmitting syphilis to the sex partner, or mixing some deleterious substance with food, leading to infirmity (ill health) to the person consuming it, etc. are all examples of hurt. Grievous Hurt (Section 320, IPC) Section 320 defines grievous hurt. Grievous hurt is more serious kind of hurt and is a specific hurt, inflicted voluntarily to another person and comprise of any of the eight kinds (clauses) enumerated below.

Definition Section 320 designates following list of eight grievous hurt: • Clause 1 — Emasculation. • Clause 2 — Permanent privation of sight of either eye. • Clause 3 — Permanent privation of hearing of either ear. • Clause 4 — Privation of any member or joint. • Clause 5 — Destruction or permanent impairment of powers of any member or joint. • Clause 6 — Permanent disfigurement of head or face. • Clause 7 — Fracture or dislocation of bone or tooth. • Clause 8 — Any hurt which endangers life or which causes the sufferer to be, during the period of 20 days, in severe bodily pain or unable to follow his or her ordinary pursuits.

Chapter 23: Trauma in its Medicolegal View Points

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Trauma in its Medicolegal View Points

Examples and Explanations Emasculation—This means depriving a male, of masculine vigour. Accordingly castration, cutting away of penis, etc. constitute ideal examples. Permanent privation of sight of either eye or hearing of either ear – To be considered as grievous hurt, the loss or privation of sight or hearing has to be permanent. Thus, injury which causes loss of vision due to fisting of the eye resulting in oedema, redness it cannot constitute the offence of grievous hurt, as the loss of vision with this injury is only of temporary nature. On the contrary, a forcible slap on the left side of face near the ear leading to permanent loss of hearing constitutes an ideal example for the offence of grievous hurt. (Note: Permanent does not mean that, it should be incurable. For example, when the loss of sight is due to corneal opacity due to some injury over corneas, it is curable by corneoplasty. But, since corneal opacity due to scarring resulting from an injury is permanent by itself, it will be considered grievous hurt and chance of cure by corneoplasty does not minimize its gravity).

Privation of any member or joint – Privation of joint means cutting away of one limb or joint, which needs no explanation. Destruction or permanent impairment of powers of any member or joint – This is self explanatory. However, any injury leading to impairment of powers of any joint or member form an ideal example to constitute this offence. Permanent disfigurement of head or face – Accordingly cutting the nose, ears or a deep wound on the cheek leading to an ugly scar, etc. which brings about permanent disfigurement changes constitutes some of the examples. This means, minor injuries on the face do not come under this section.

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Note: However, when we consider disfigurement factor, grievousness may not be same in all persons. An irregular small, permanent scar on the face of a young unmarried girl or a stage or cinema actress may be considered as grievous hurt, because this may affect her life and career as well as livelihood, most adversely. But, such a scar in an old woman may not be considered for the purpose of this offence to have disfigured her face as her face may be already having multiple creases and other scars due to aging.

Fracture or dislocation of bone or tooth: This is considered as grievous hurt (irrespective of size or extent), because it can cause great pain and suffering to the injured. Bone need not cut through and through or crack need not extend to the whole thickness of bone. Partial cut of the bone or fracture of outer table alone as with the fracture skull, come under this clause. Note: However, dislocation of bone may not be a feature to persist for long but dislocation of tooth may retain the feature for considerably long period or may even be a permanent feature when the dislocated tooth falls off.

Eighth clause: Under this clause hurt which endangers life, meaning injury which may or may not be likely to cause death in ordinary course of nature, irrespective of whether treatment is given or not. As regards severe bodily pain, it is correct that, one or two bruises or abrasions may not be considered as grievous hurt. However, multiple bruises and abrasions involving excessive body surface may amount to grievous hurt, in a way causing severe bodily pain or even endangering the life. Thus, only if the injury causes danger to life of the patient, it becomes grievous. The phrase “unable to follow his ordinary pursuit” for 20 days means the person is unable to go to the toilet by himself, taking bath himself, or taking food himself, for 20 days. Ordinary pursuits also mean those activities by which a person earns his livelihood (e.g. a taxi driver cannot earn his livelihood if another person has caused fracture of his upper limb intentionally). Thus to say one is suffering from grievous hurt, mere hospital stay for 20 days is not enough. It must be proved that during the stay, he was either in severe bodily pain or unable to follow his ordinary pursuits. Punishment for Hurt and Grievous Hurt Sections 323, 324, 325 and 326 IPC, describe the punishments for hurt and grievous hurt, are given below.

Section 323, IPC Punishment for voluntarily causing hurt – imprisonment up to one year or with fine up to Rs. 1000 or both. Section 324, IPC Punishment for voluntarily causing hurt by dangerous weapons or means–imprisonment up to three years or fine or with both. Section 325, IPC Punishment for voluntarily causing grievous hurt –imprisonment up to seven years and fine. Section 326, IPC Punishment for voluntarily causing grievous hurt by dangerous weapons or means—life imprisonment or imprisonment upto for ten years and fine. These two sections create the need for understanding the two terms–dangerous weapon and means causing hurt or grievous hurt. 330

Dangerous Weapon Instruments used for shooting, stabbing or cutting or any other instrument which is used as a weapon of offense is likely to cause death, constitute dangerous weapons. Means Causing Hurt or Grievous Hurt Fire, heated substances, a poison or corrosives, or explosives, or any substance deleterious to the body to inhale, swallow, or received into the blood or by means of animal constitute means causing hurt or grievous hurt. HOMICIDE Homicide means causing the death of one person, by the act of another. Homicide is punishable under certain circumstances (culpable homicide) and not punishable under other circumstances (excusable or justifiable). Thus homicide can be lawful and unlawful (Fig. 23.1). Each of these is presented below with relevant IPC sections. LAWFUL HOMICIDE These homicides which are not punishable and also known as simple homicide are enumerated as follows: • Homicide done by a person of unsound mind (Section 84, IPC) • Homicide by a child below the age of 7 years (Section 82, IPC) • Homicide due to an accident/misfortune (e.g.: firing into a bush thinking that there is a rabbit and accidentally shooting a human being instead) (Section 80, IPC) • Homicide during private defence of body or property, e.g.: personal defence in order to prevent death or rape (Section 100, IPC), or private defence of property (Section 103, IPC) e.g. inn robbery. • Homicide done as per the order of the court (Judicial hanging) (Section 78, IPC) UNLAWFUL HOMICIDE Culpable Homicide (Section 299, IPC) This is also known as culpable homicide not amounting to murder (Manslaughter in UK).

Definition Culpable homicide is defined as causing of death by doing an act: • With an intention of causing death or • With the intention of causing such bodily injury as is likely to cause death or • With the knowledge that he is likely to cause death by such act. Examples • Immersing the head of a child under water column proves the intention to cause death. • Firing a revolver aimed at the head of another person also proves the intention. • Causing multiple injuries resulting in rib fractures, compound fracture of femur, rupture of one kidney, etc. shows that the intention to cause bodily injuries are likely to cause death. • Over a trivial quarrel in dim light, A threw a knife at B. It pierced the chest and caused death of B. There was no attempt to cause any more injury. Here A had the knowledge that he is likely to cause death by his Act.

Chapter 23: Trauma in its Medicolegal View Points

Fig. 23.1: Murder: Different types and punishments

Explanation: This Section says that if death is caused by bodily injury, the person causing it shall be deemed to have caused death even if death could have been prevented by restoring to proper skillful treatment (Proper remedy and treatment may not be within the reach of the wounded man. Even if proper treatment is present, he may refuse to get it. In such cases if the wounded man dies, the person who caused the injury is deemed to have caused the death). Punishment for Culpable Homicide Not Amounting to Murder (Section 304, IPC) • Life imprisonment or imprisonment up to 10 years and fine if the act by which death is caused is done with the intention of causing death or such bodily injury as is likely to cause death. • Imprisonment up to 10 years or fine, or both if the Act is done with the knowledge that it is likely to cause death. Murder (Culpable Homicide Amounting to Murder) (Section 300, IPC) Causing death by an Act done: • With the intention of causing death/kill. Example – Stabbing on the heart with a dagger. • With the intention of causing such bodily injury as the offender knows to be likely to cause death. Here the assailant knows about the state of ill health of the victim and that the injury caused is likely to cause death in such a state of health, even though such an injury would not ordinarily have caused death of a healthy person. Example – A hits over the area of spleen on the abdomen of B knowing fully well that it is enlarged and thus, rupture it. • With the intention of causing such bodily injury, as is sufficient to cause death in the ordinary course of nature. Here, as a result of the intentional act causing injury, the probability of death is very high. (If the probability of death is lesser, then, it is an injury which is likely to cause death – refer culpable homicide not amounting to murder).

Thus a stab injury into a vital organ like heart or a major blood vessel is sufficient to cause death in the ordinary course. The intention to cause injury, which is sufficient in the ordinary course of nature to cause death, is absolutely necessary for making the offence of murder. If during a struggle, the accused merely swing his knife towards the leg of the victim and by a misfortune a blood vessel of the leg was cut leading to death of the victim, the offence cannot be called as murder, as there was no intention to cause death or to cause an injury, which is sufficient in the ordinary course of nature to cause death. (At the most, we can say that the accused had an intention to cause merely an injury on the leg). It is true that the injury caused was sufficient to cause death in the ordinary course as a major blood vessel was cut; however, the accused did not have the intention to cause it. Hence, his crime will fall under culpable homicide not amounting to murder. • With knowledge that the act is so imminently dangerous that it must in all probability cause death or such bodily injury as is likely to cause death. Here the accused is presumed to have known that his act is imminently dangerous. Example – Inflicting serious injury on the neck with an axe or chopper, firing a gun into a crowd, etc. Exceptions: Five exceptions are given in Section 300 IPC, whereby, culpable homicide will not become murder, and they are: i. Causing death by grave and sudden provocation: Example – husband finds his wife in bed with her paramour unexpectedly. He kills the man then and there. The offence is only culpable homicide and not murder. ii. Causing death by exceeding the right of private defence: Example – A slapped B on his cheek. B stabbed A on the heart, and caused his death. Here B had exceeded his right of private defence of body. So he is guilty of only culpable homicide. 331

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iii. Public servant exceeds the powers given by law and causes death. Example – Police constable accompanying the convicted person (on the way to court) kills him by firing revolver when the convict tried to escape from custody. iv. Death caused without premeditation in sudden flight, in the heat of passion. Example – Room mates (friends) get involved in a sudden flight on some trivial matter and one gets killed. If there was sufficient time for passion to subside and reason to interpose, the killing will become murder. So suddenness of the flight is important. v. A person aged above eighteen years suffers death or takes the risk of death with his own consent. Example – A doctor gives some poison to a cancer patient, who, due to the pain and suffering, pleads for it and thus death ensues (mercy killing). Differences between Grievous Hurt, Culpable Homicide and Murder The line between grievous hurt and culpable homicide not amounting to murder is very thin. In the former, the injury should endanger life and in the latter, the injury must be of the nature which is likely to cause death. Thus, if the culpable homicide is genus, murder is a species. All murders are necessarily culpable homicides but not the vice versa. The Penal Code recognises three degrees of culpable homicide in order to fix punishment proportionate to the gravity of offence.1-15 1. Culpable homicide of first degree – the gravest form of culpable homicide also called as ‘murder’ (Section 300, IPC). 2. Culpable homicide of the second degree – punishable under the first part of Section 304, IPC. 3. Culpable homicide of the third degree – lowest form of culpable homicide punishable under the second part of Section 304, IPC. Mental Elements in Culpable Homicide The offence of culpable homicide supposes an ‘intention’ or ‘knowledge’ of likelihood of causing death. In the absence of such intention or knowledge, the offence committed may become grievous hurt or hurt, even if death is caused. Thus, if death is caused by an injury, which the offender did not know would endanger life or would be likely to cause death, it is treated as only grievous hurt or simple hurt. But, if the act was deliberate, and was not the result of an accident, rashness or negligence, then it becomes culpable homicide. Case law: In the course of an altercation on a dark night, the accused ‘A’ aimed a blow at ‘B’ with a stick. To ward off the blow, the wife of ‘B’ who had a child in her arm, intervened between ‘A’ and ‘B’. The blow missed its aim and fell on head of the child, who died due to head injury. In this case, the accused was held guilty of simple hurt only. (He had the intention to cause hurt only on ‘B’. it was not a violent blow intended to cause death (culpable homicide) or endanger life (grievous hurt). Thus, the Court approaches the problem in three stages: 1. Was death caused by the act of accused another parson? (i.e. is it a homicide?) 2. Was it culpable homicide? (i.e. it is not coming under any of the exceptions mentioned under Lawful homicide) 3. a. If the act does not come under any one of the four clauses under Section 300, IPC, it will only be culpable homicide not amounting to murder.

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b. If the act comes under any of the four clauses of Section 300, IPC, but, at the same time, it comes under any of the five exceptions (refer above) given under Section 300, IPC, then again, it is culpable homicide not amounting to murder. c. If the act comes under any one of the four clauses in Section 300, IPC, and does not fall under any of the five exceptions mentioned in Section 300, IPC, it becomes murder. Injury likely to Cause Death and Injury Sufficient to Cause Death in the Ordinary Course of Nature: (Refer above). Punishment for Murder (Section 302, IPC) – death or imprisonment for life and fine. Rash or Negligent Homicide (Section 304 A) If death of a person is caused by any rash or negligent act, not amounting to culpable homicide, the punishment is imprisonment up to 2 years, or fine or both.

Rash and Negligent Act Here, the person doing the act is conscious that a dangerous consequence may follow; however he hopes that it may not result in that particular case e.g.: Penicillin injection given without a test dose. But since the doctor had no intention to cause death, it is not considered as culpable homicide. It may be noted that he would be charged for criminal negligence under this section. Section 336, IPC Deals with rash and negligent act endangering human life or personal safety of others (up to 3 months imprisonment or fine up to Rs. 250 or both). Here punishment is given even though no harm is actually caused. Rash act means, something more than mere inadvertence or want of ordinary care. It implies an indifference to obvious consequences. For example, a doctor may give penicillin injection without doing a test dose, knowing fully well the consequences of penicillin reaction, but neglecting to do test. It is typical example of a rash act. If the patient suffers a reaction because of it, Section 335, IPC, is applicable. If the patient dies due to it, Section 304A IPC comes in play. Section 337, IPC Rash and negligent act leading to hurt caused to another person (up to 6 months imprisonment or fine up to Rs. 500 or both). Section 338, IPC Rash and negligent act leading to grievous hurt caused to another person (up to 2 years imprisonment or fine up to Rs. 1000 or both). Abetment of Suicide (Sections 305, 306, IPC) It is also considered as unlawful homicide, since the accused is abetting or aiding the victim in committing suicide. It may be noted that if the person who wants to die asks another person to kill him, then it becomes culpable homicide only (i.e. by consent). • Punishment for abetment of suicide (Section 306, IPC): the person abetting the suicide of another person shall be punished with imprisonment up to 10 years and shall also be liable to fine. • Attempt to commit suicide (Section 309, IPC): If any act towards the commission of suicide is done, the punishment is imprisonment up to one year, or fine, or both.

EXAMINATION OF AN INJURED1-5 Any case of injury is a potential medicolegal issue. When a case of injury is referred, normally the doctor will concentrate on providing all the best services as to save the life of the victim. However, an equally important entity that has to be taken into consideration at this juncture is the medicolegal management of the case. Usually this remains unattended and ignored unintentionally by the doctor mainly due to lack of knowledge about the same. A schematic representation on managing trauma case is shown in Figure 23.2. MEDICAL MANAGEMENT Medical management is mainly the treating clinician’s concern and includes the following four steps: • Save life • Proper diagnosis (use all available laboratory diagnostic aid) • Proper treatment • Hospitalisation if necessary. Medicolegal Management Medicolegal management includes specific and general measures.

I. • • • •

Specific Measures Consent for the examination of the injured Informing the police (Appendix-1) Confidentiality of medical examination findings of the patient. If the patient is conscious, ask him as to how the injury was caused. Record it in patient’s own words. If the patient dies later, it will be accepted as dying declaration by the court. If the injured is unconscious, ask the friends/ relatives accompanying him. In such cases, it must be mentioned in the wound certificate (i.e. as informed by the relatives/ friends).

Fig. 23.2: Managing a trauma case

II. General Measures 1. Prepare, preserve and maintain the following documentary requirements. • Accident register/wound register (Appendix-2) • Case sheet, date, time of examination and observations noted • Special reports or other laboratory test reports • Hospital discharge certificate (Appendix-3) • Dying declaration – whenever death is likely to occur. • Death certificate – is not issued unless postmortem examination is completed. 2. In doubtful circumstances • Consult a professional colleague available nearby • Refer standard textbook • Refer the case to another hospital with better facilities (Appendix-4) • Perform the clinical and other essential medical investigation procedure as available to confirm the diagnosis, e.g. radiographic examination in suspected case of fractures.

Chapter 23: Trauma in its Medicolegal View Points

Dowry Death (Section 304 B, IPC) When death of woman is caused within seven years of her marriage and it is shown that soon before her death she was subjected to cruelty or harassment by her husband or any relatives of the husband for, or in connection with any demand for dowry such husband/ relative shall be deemed to have caused her death. The punishment for such dowry related death is imprisonment for not less than seven years, but may be extended to life imprisonment.

COMPLICATIONS OF INJURIES Injuries of Medicolegal Importance This includes certain specific injuries2,3,4,7-15 (refer Chapters 16 to 19 for details), and are as follows: 1. Hesitation cuts 2. Defense wounds/cuts 3. Self-inflicted wounds (fabricated wounds). These are wounds inflicted by oneself on his/her own body for false accusation purposes, e.g. artificial bruises. 4. Crush syndrome It constitutes multiple injuries, as seen with road traffic accidents and such other cases, wherein death may result due to renal failure. 5. Concealed punctured wound 6. Head injuries—following head injuries are important medicolegally: i. Coup and contrecoup injuries ii. Cerebral concussion iii. Cerebral compression iv. Lucid interval. 7. Homicide and suicide 8. Injuries and volitional acts 9. Fatal wound—if an injury is present on a cadaver, then the question arises as to whether the injury could have been fatal in the normal course, if death is a result of this injury or could he have died of some other cause. If the victim dies after the injury and has no other cause detected to account for death, then we can conclude it as fatal wound. Injury to vital organs can also be opined as fatal wounds. When many injuries are present, opinion can be given as death is due to cumulative effect of all injuries, e.g. multiple contusions. When complication of wound results death is confirmed by meticulous autopsy and opinion should be given as “deceased died because of the complications of the wounds sustained.” 10. Necessarily fatal Injuries (imminently fatal Injuries)—Injuries that end in death as a direct result of the injury irrespective of any medical aid constitutes necessarily fatal injury. Some examples – crush injury to head, decapitation, and separation of body into two or more fragments (railway accidents). 333

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11. Injuries likely to cause death and Injuries sufficient in the ordinary course of nature to cause death—The former is given in the definition of culpable homicide (Section 299 IPC) and the latter in the definition of murder (Section 300 IPC). The distinction between the two is fine but real. In fact it is the degree of probability of death, which makes the distinction. ‘Likely to cause death’ means that it is not just a possibility, but it is probable. ‘Injury sufficient to cause death in ordinary course’ denotes that death will be the most probable result of injury in ordinary course. In ‘Likely to cause death’, death is not a surprise. Some examples are: • A blow from the front by a stick on the head causing scalp contusion and concussion; • Multiple contusions over the body. 12. In Injury sufficient to cause death in ordinary course – survival of the victim is surprise. Some of the commonly

encountered injuries which can be quoted as examples are: • A stab wound or rupture of heart; Injury to large blood vessels; • Stab on the chest/abdomen; • Blow on the head with an iron rod causing comminuted fracture of skull, intracranial hemorrhages and laceration of brain. • Incised wound of the neck – as such is not an injury sufficient to cause death. Unless the major neck vessels and trachea are cut, this is only an injury which endangers life, i.e. grievous hurt. • Squeesing of the testicles–as such is not an injury sufficient to cause death. Unless the major vessels are cut, it is only an injury which endangers life, i.e. grievous hurt; • Burns > 1/3rd of the body surface; • Administration of large dose of poison.

APPENDICES Appendix 1: Police Intimations Given below is the standard format of Police intimation letters giving information about a Medico-legal Case (e.g. Road Traffic Accident Case, Unnatural Death Case, Brought Dead Case, Dead on Arrival to Hospital Case, etc.) to the Police. It is the duty of the medical officer (DMO) to inform about all such cases to police as any other citizen, which, if not done amounts to suppression of evidence and is punishable. Details of death may be informed to the nearest police station by phone, followed by a written intimation in specific format given below.

Medicolegal Case Police intimation letter on a medicolegal case is drafted as shown below: Ref. No: .............................................

Place: ............................................. Date: .............................................. Time: .............................................

From: Name of MO Designation Name of Institution/Hospital Address To: The Sub-Inspector of Police Name of Police Station Address Sir,

I write to inform you that a patient by name ................................................. aged about ............. inhabitant of (Address) ..................……………………….......................................................................................................... has been brought into the casualty/ outpatient department (OPD) of …..............…..................... Hospital, at .............. AM/PM On …….............. is alleged to have been ...............……………… at ….……. AM/PM at (place) .....................…………………………………………………………………….. He/she is being treated as outpatient/inpatient in Ward No. ............…………………... Please do the needful. Yours faithfully Signature Name ................................................................................................. Reg. No. ............................................................................................ Designation ....................................................................................... Address .............................................................................................. 334

Official Seal .......................................................................................

The doctor who attends the injured patient usually has to record the details of the injuries found, in the Accident-Register-cum-Injury or Wound Report/Certificate. The duty doctor should keep this register under safe custody. The forms in the register are arranged in duplicates making a carbon copy. The original of the Injury or Wound Report/Certificate, is to be detached and issued to the Police Officer. The carbon copy will remain in the register and serve as a permanent record for the Medical Officer. The standard formats of the accident register and injury/wound certificate are given below:

Accident Register 1. Serial No. ........................ Date and hour of examination: .................................. 2. Name: ............................................................ Age: ...................................... Sex: .............................................. 3. Address: ............................................................................................................................................................................................... 4. Marks of identification a. ....................………………………………………………………………. b. ....................………………………………………………………………. 5. Brought by: 6. History and alleged cause of injury. 7. Details of injuries/clinical features. 8. No. of additional sheets, if any 9. Is dying declaration required? 10. If yes, whether Police/Magistrate is informed? 11. Investigation result, if any 12. Date of admission as inpatient and IP No. 13. Date of discharge 14. Condition on discharge 15. Opinion as to cause of injury Name of Institution

Signature of DMO*

Station

Name of DMO

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Appendix 2: Injury/Wound Report

Registration No: Date

Designation Address: Official Seal

Issued to ...................................... of Police Station, as per his requisition No. ................................ Dated .......................................... *

Duty Medical Officer (DMO)

Injury Report Also known as Injury Certificate/Wound Certificate Ref. No.: ……………

Place: ……….

Date: ………….

Time: …………………

Name: …………………………………………………… Age: ……………. Sex: …..……………....... Address: ……………………………………………………………………………………………................................................................... ………………………………………………………….…………………………………...……….................................................................... Brought and Identified by the Police: Constable No. ....................... Name: .................................................................................................... of Police Station ................................................................................................................................................................................................................................ Informed Consent: Question asked ..............……………………………………………..........…………………….................…………………………………………….............. Reply given ..............……………………………………………..........…………………….................……………………………………... 335

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Signature/Left hand thumb impression of consenting person: Marks of Identification: 1. ..…………………………………………….....…… 2. ..…………………………………………….....…… Brief history: ……………………………………………………………………………………………. General Examination: Details about the injury/wounds S.No.

Type

Size—Dimensions

Other aspects Location

Simple or grievous

Kind of causative weapon

Time since injury

Other remarks

1. 2. 3. 4. 5. Name & Signature of DMO: Designation: Reg. No.: Official Seal:

Appendix 3: Discharge Certificate Issuing a Discharge Certificate of an injury case registered as medicolegal is very important. It may be drafted as below and sent to the concerned Police authority:

Hospital Discharge Certificate Ref. No. ............................................................................................. From Name of MO ................................................................................................................................................................................................... Designation ..................................................................................................................................................................................................... Name of Institution .......................................................................................................................................................................................... Station .................................................................................................................................................................................................... To The SI of Police .............................................................................................................................................................................................. Address of Police Station .................................................................................................................................................................................. ........................................................................................................................................................................................................................................................ Sir,

In continuation of wound certificate No. .............. dated ...................... I have informed you that Sri/Smt/Kum .............………………………………………........................................................................................................................................................ aged ....……….....................… was admitted on ….................................. in our hospital, IP No.......……………….................................. He/she is discharged/cured/relieved on...............……. . Given below are further comments about the case: a. X-ray and other special investigations....................………………………………………….................................................................... b. The following surgeons and specialists were concerned in the treatment of the case ................................................................... ......................................................................................................................................................................................................................... c. Other relevant information .................................…...............................................................……..................................................... Place................………….

Name & Signature................……….............................

Date..................…………

Registration No.................…………............................ Designation & address........………......................... Official Seal:

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For referring injury cases it is better to observe following formalities: 1. All medicolegal (injury) cases brought to a hospital should be examined by the Medical Officer first and treatment given. 2. However, if the patient is to be shifted to another hospital due to want of adequate facilities for treatment in the first hospital, necessary first aid should be given by the Medical Officer who examined the patient first. 3. A copy of the accident register/wound certificate should invariably accompany the patient referred to the next institution. 4. If the injured was admitted and treated in the first hospital and later referred to a second hospital for advance treatment, the Medical Officer of the first hospital should issue the wound certificate to the Police Officer so that it can be produced before the Medical Officer in the second hospital who continues the treatment of the injured. 5. Discharge certificate is issued by the attending doctor of the referral hospital (As in Appendix-3).

REFERENCES 1. Chandran MR (Ed). Guharaj’s Forensic Medicine. Orient Longman: India, 2004. 2. Rao NG. Practical Forensic Medicine (3rd edn). Jaypee brothers medical Publishers Ltd, New Delhi, 2007. 3. Nandy A. Principles of Forensic Medicine, Reprint edn. New Central Book Co., Kolkata, 2002. 4. Mathiharan K, Patnaik AK (Eds): Modi’s Medical Jurisprudence and Toxicology (23rd edn). Lexis Nexis Butterworth’s 2006. 5. Mukharjee JB. Forensic Medicine and Toxicology. Arnold: Kolkata, 1995. 6. Krishnan MKR. Handbook of Forensic Medicine and Toxicology. Kothari Books: Hyderabad, 1992. 7. Major Criminal Acts, Athul Law Agency: Allahabad, 1989. 8. Indian Penal Code (Act No: XIV of 1860 as amended, 1988), Central Law Agency: Allahabad, India, 1989.

9. Chandrachud YV, Manohar VR, Avtar Singh, Ratanlal, Dhirajlal. The Indian Penal Code (Act XLV of 1860), (30th edn). (Thoroughly Revised and Revitalised), Wadhwa and Co. Nagpur, New Delhi, 2004. 10. Chandrachud YV, Manohar VR, Avtar Singh. The Code of Criminal Procedure (Act II of 1974), (17th edn). (Thoroughly Revised and Revitalised), Wadhwa and Co. Nagpur, New Delhi, 2004. 11. Parikh CK. Parikh’s Medical Jurisprudence and Toxicology for Courtroom and Classroom (6th edn). CBS Publishers: Mumbai, 2002. 12. Rao NG. Forensic Pathology (6th edn). HR Publication Aid: Manipal, 2002. 13. Rao NG. Clinical Forensic Medicine, HR Publication Aid: Manipal, 2004. 14. Sukho P (Ed). B. Knight’s Forensic Pathology, (3rd edn). Arnold: London, 2002. 15. Eckert W. Transportation injuries. In Tedeschi L, Eckert WB (Eds): Forensic Medicine. WB Saunders: Philadelphia, 1977.

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Appendix 4: Referring an Injury Case to Second Hospital

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24

Domestic Violence— Medical and Legal Aspects

INTRODUCTION Synonyms for domestic violence include partner violence, relationship violence, and intimate partner abuse, spouse abuse, domestic abuse, and wife abuse, wife beating, and battering. Domestic violence is also described as a “pattern of interaction” in which one intimate partner is forced to change his or her behavior in response to the abuse or threats of the other partner. Domestic violence is considered to have occurred when one intimate partner uses physical violence, coercion, threats, intimidation, isolation, and/or emotional, sexual, and economic abuses over the other intimate partner to maintain power and control. Domestic violence refers to the victimisation of a person with whom the abuser has or has had an intimate, romantic, or spousal relationship. Domestic violence encompasses violence against both men and women and includes violence in gay and lesbian relationships.1,2 DEFINITION The domestic violence in India is defined by the Protection of Women from Domestic Violence Act 2005. Accordingly, the term domestic violence includes elaborately all forms of actual abuse or threat of abuse of physical, sexual, verbal, emotional and economic nature that can harm, cause injury to, endanger the health, safety, life, limb or wellbeing, either mental or physical of the aggrieved person. The definition is wide enough to cover child sexual abuse, harassment caused to a woman or her relatives by unlawful dowry demands, and marital rape.

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or adolescent. These behaviors, which can occur alone or in combination, sporadically or continually, include three types:3 • Physical violence, • Psychological abuse, and • Nonconsensual sexual behavior. Each one is discussed individually. However, it may be noted here that, each incident builds upon previous episodes, thus setting the stage for future violence. Physical Violence Among the variety of physical violence observed, pushing, shoving, slapping, punching, choking, kicking, holding, binding, assault with weapons are frequent. Usually two forms of physical violence have been noticed at home and they are: occasional outbursts of bidirectional violence (i.e., mutual combat) and frank terrorism.4 According to United States of America Preventive Services Task Force survey among the frank terrorist type patriarchal (male dominating) form of domestic violence, is more prevalent.5

INCIDENCE Domestic violence affects people from all races, religions, age groups, sexual orientations, and socioeconomic levels. Victims/ persons of domestic violence are mostly women and they usually belonging to one of the following three categories: 1. Single and legally divorced, recently widowed, recently separated, recently sought an order of protection, younger than 28 years of age, addicted to alcohol or other drugs, pregnant, having excessively jealous or possessive partners. 2. Witnessed or experienced physical or sexual abuse as children. 3. Have partners who have witnessed or experienced physical or sexual abuse as children.

Psychological Abuse This includes threats of physical harm to the patient or others, intimidation, coercion, degradation and humiliation, false accusations, and ridicule. Annoyance may occur during a relationship, or during and after a relationship has ended. Of women who are stalked by an intimate partner, 81 per cent are also physically assaulted. 6 A new development is psychological abuse (generally threats) expressed through the Internet, so-called cyberstalking. Usually the Cyberstalkers target their victims through chat rooms, message boards, discussion forums, and e-mail. Cyberstalking takes many forms such as: threatening or obscene e-mail; spamming (in which a stalker sends a victim a multitude of junk e-mail); live chat harassment or flaming (online verbal abuse); leaving improper messages on message boards or in guest books; sending electronic viruses; sending unsolicited e-mail; tracing another person’s computer and Internet activity, and electronic identity theft.7,8 Recent federal law has addressed cyberstalking as well. The Violence Against Women Act passed in 2000, made cyberstalking a part of the federal interstate stalking statute in USA.9

MEDICAL ASPECTS OF DOMESTIC VIOLENCE Domestic violence consists of a pattern of coercive behaviors used by a competent adult or adolescent to establish and maintain power and control over another competent adult

Sexual Abuse This may include nonconsensual or painful sexual acts (often unprotected against pregnancy or disease). Sexual abuse under domestic violence is said to have occurred when any one of

EFFECTS OF DOMESTIC VIOLENCE ON CHILDREN AND TEENAGERS When describing the effects of domestic violence on children, it is important to note that domestic violence and child abuse are often present in the same families. In homes where domestic violence occurs, children are physically abused and neglected at a rate 15 times higher than the national average. Several studies have shown that in 60 to 75 per cent of families in which a woman is battered, children are also battered. In addition; children living in households where domestic violence is occurring are at a higher risk for sexual abuse.11 Many children in families where domestic violence has occurred appeared to be “parentified.” They are forced to grow up faster than their peers, often taking on the responsibility of cooking, cleaning and caring for younger children. Many of these children were not allowed to have a real childhood. They do not trust their fathers because of his role as an abuser and they may have been worried about what to expect when coming home. They learned at a young age to be prepared for anything. Children may also be isolated. Typical activities such as having friends over to their house may be impossible due to the chaotic atmosphere. Kids aren’t going to have their friends over home when mom has a black eye. However, school performance is not always obviously affected. Children may respond by being overachievers. Children in domestic violence tend to be either extremely introverted or extremely extroverted. Psychosomatic problems (aches and pains for no apparent reason) are common; these children’s eating and sleeping patterns tend to be disrupted. Children who witness domestic violence Domestic violence can wipe out a child’s confidence and leave them shocked. Infants and toddlers who witness violence show excessive irritability, immature behavior, sleep disturbances, emotional distress, fears of being alone, and regression in toileting and language, and may develop behavior problems, including aggression and violent outbursts.12-14 Teenagers living with domestic violence face the unique problem of trying to fit in with their peers while keeping their home life a secret. Teens in shelters often face the problem of having to move and begin school in a new place, having to make new friends while feeling the shame of living in a shelter. Needless to say, their family relationships can be strained to the breaking point. The result can be teens who never learn to form trusting, lasting relationships, or teens who end up in violent relationships themselves, ending up in violent relationships as adults either as victims or abusers.11-14 DOMESTIC VIOLENCE AND LAW—INDIAN SCENARIO India is a developing nation and though there are cases of domestic violence, it is very rarely reported as for a wife husband

is everything after marriage and she will some how cope up with her husband of whatever nature he is and lives with him without reporting the incidence if violence at home to any one. In certain instances the elders in the family when note these being a joint family culture try their level best in counseling such episodes without reporting to authorities. Even the family physician/general practitioners whenever suspect such instances hesitate to report for the fear that the problem may become worse to the victim when reported to authority. India has adopted the Convention on the Elimination of All Forms of Discrimination against Women and the Universal Declaration of Human Rights, both of which ensure that women are given equal rights as men and are not subjected to any kind of discrimination. The Constitution of India also guarantees substantive justice to women. Article 15 of the Constitution provides for prohibition of discrimination against the citizens on grounds of religion, race, caste, sex or place of birth or their subjection to any disability, liability or restriction on such grounds. Article 15 (3) gives power to the legislature to make special provision for women and children. In exercise of this power, the Protection of Women from Domestic Violence Act was passed in 2005.

Chapter 24: Domestic Violence—Medical and Legal Aspects

the following several forms between an intimate partners has taken place:10 • Minimised the importance of your feelings about sex • Criticised you sexually • Insisted on unwanted or uncomfortable touching • Withheld sex and affection • Forced sex after physical abuse or when you were sick • Raped you • Been jealously angry, assuming you would have sex with anyone • Insisted that you dress in a more sexual way than you wanted.

THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005 Main Features of the Act The kinds of abuse covered under the Act are: 1. Physical Abuse • An act or conduct causing bodily pain, harm, or danger to life, limb, or health; • An act that impairs the health or development of the aggrieved person; • An act that amounts to assault, criminal intimidation and criminal force. 2. Sexual Abuse: Any conduct of a sexual nature that abuses, humiliates, degrades, or violates the dignity of a woman. 3. Verbal and Emotional Abuse • Any insult, ridicule, humiliation, name-calling; • Insults or ridicule for not having a child or a male child; • Repeated threats to cause physical pain to any person in whom the aggrieved person is interested. 4. Economic Abuse • Depriving the aggrieved person of economic or financial resources to which she is entitled under any law or custom or which she acquires out of necessity such as household necessities, stridhan, her jointly or separately owned property, maintenance, and rental payments; • Disposing of household assets or alienation of movable or immovable assets; • Restricting continued access to resources or facilities in which she has an interest or entitlement by virtue of the domestic relationship including access to the shared household. 5. Domestic Relationship: A domestic relationship as under the Act includes live-in relationships and other relationships arising out of membership in a family. 6. Beneficiaries under the Act: • Women: The Act covers women who have been living with the Respondent in a shared household and are related to him by blood, marriage, or adoption and 339

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includes women living as sexual partners in a relationship that is in the nature of marriage. Women in fraudulent or bigamous marriages or in marriages deemed invalid in law are also protected. • Children: The Act also covers children who are below the age of 18 years and includes adopted, step or foster children who are the subjects of physical, mental, or economical torture. Any person can file a complaint on behalf of a child. • Respondent: The Act defines the Respondent as any adult male person who is or has been in a domestic relationship with the aggrieved person and includes relatives of the husband or male partner. Shared Household: A shared household is a household where the aggrieved person lives or has lived in a domestic relationship either singly or along with the Respondent. Such a household should be owned or tenanted, either jointly by both of them or by either of them, where either of them or both of them jointly or singly have any right, title, interest or equity in it. It also includes a household that may belong to the joint family of which the respondent is a member, irrespective of whether the respondent or person aggrieved has any right, title or interest in the shared household. RIGHTS GRANTED TO WOMEN Right to reside in a shared household: The Act secures a woman’s right to reside in the matrimonial or shared household even if she has no title or rights in the household. A part of the house can be allotted to her for her personal use. A court can pass a residence order to secure her right of residence in the household. The Supreme Court has ruled in a recent judgment that a wife’s claim for alternative accommodation lie only against her husband and not against her in-laws and that her right to ‘shared household’ would not extend to the self-acquired property of her in-laws. Right to obtain assistance and protection: A woman who is victimised by acts of domestic violence will have the right to obtain the services and assistance of Police Officers, Protection Officers, Service Providers, Shelter Homes and medical establishments as well as the right to simultaneously file her own complaint under Section 498 A of the Indian Penal Code for matrimonial cruelty. Right to issuance of orders: She can get the following orders issued in her favour through the courts once the offence of domestic violence is prima facie established: • Protection Orders: The court can pass a protection order to prevent the accused from aiding or committing an act of domestic violence, entering the workplace, school or other places frequented by the aggrieved person, establishing any kind of communication with her, alienating any assets used by both parties, causing violence to her relatives or doing any other act specified in the Protection order. • Residence Orders: This order ensures that the aggrieved person is not dispossessed, her possessions not disturbed, the shared household is not alienated or disposed off, she is provided an alternative accommodation by the respondent if she so requires, the respondent is removed from the shared

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household and he and his relatives are barred from entering the area allotted to her. However, an order to remove oneself from the shared household cannot be passed against any woman. Monetary Relief: The respondent can be made accountable for all expenses incurred and losses suffered by the aggrieved person and her child due to the infliction of domestic violence. Such relief may include loss of earnings, medical expenses, loss or damage to property, and payments towards maintenance of the aggrieved person and her children. Custody Orders: This order grants temporary custody of any child or children to the aggrieved person or any person making an application on her behalf. It may make arrangements for visit of such child or children by the respondent or may disallow such visit if it is harmful to the interests of the child or children. Compensation Orders: The respondent may be directed to pay compensation and damages for injuries caused to the aggrieved person as a result of the acts of domestic violence by the respondent. Such injuries may also include mental torture and emotional distressed caused to her. Interim and Ex parte Orders: Such orders may be passed if it is deemed just and proper upon commission of an act of domestic violence or likelihood of such commission by the respondent. Such orders are passed on the basis of an affidavit of the aggrieved person against the respondent.

Right to obtain relief granted by other suits and legal proceedings: The aggrieved person will be entitled to obtain relief granted by other suits and legal proceedings initiated before a civil court, family court or a criminal court. LIABILITIES AND RESTRICTIONS IMPOSED UPON THE RESPONDENT 1. He can be subjected to certain restrictions as contained in the Protection and Residence order issued against him. 2. The respondent can be made accountable for providing monetary relief to the aggrieved person and her children and pay compensation damages as directed in the compensation order. 3. He has to follow the arrangements made by the court regarding the custody of the child or children of the aggrieved person as specified in the Custody order. The Act does not permit any female relative of the husband or male partner to file a complaint against the wife or female partner. AUTHORITIES RESPONSIBLE AND THEIR FUNCTIONS The Act provides for appointment of Protection Officers and Service Providers by the State Governments to assist the aggrieved person with respect to medical examination, legal aid, safe shelter and other assistance for accessing her rights. Protection Officers: These are officers who are under the jurisdiction and control of the court and have specific duties in situations of domestic violence. They provide assistance to the court in preparing the petition filed in the magistrates office, also called a Domestic Incident Report. It is their duty to provide necessary information to the aggrieved person on Service Providers and to ensure compliance with the orders for monetary relief.

Court of First Class Judicial Magistrate or Metropolitan Magistrate: This shall be the competent court to deal with cases of domestic violence and within the local limits of this court, either of the parties must reside or carry on business or employment, or the cause of action must have arisen. The Magistrate is allowed to hold proceedings in camera if either party to the proceedings so desires. General Duties of Police Officers, Service Providers and Magistrate: Upon receiving a complaint or report of domestic violence or being present at the place of such an incident, they are under a duty to inform the aggrieved person of: • Her right to apply for obtaining a relief or the various orders granted under the Act; • The availability of services of Service Providers and Protection Officers; • Her right to obtain free legal services; and • Her right to file a complaint under Section 498 A of the Indian Penal Code.

• •

• • •

•

Officer, and Service Provider or can directly file a complaint with a Magistrate for obtaining orders or reliefs under the Act. The informant who in good faith provides information relating to the offence to the relevant authorities will not have any civil or criminal liability. The court is required to take cognizance of the complaint by instituting a hearing within three days of the complaint being filed in the court. The Magistrate shall give a notice of the date of hearing to the Protection Officer to be served on the Respondent and such other persons as directed by the Magistrate, within a maximum period of 2 days or such further reasonable time as allowed by the Magistrate. The court is required to dispose of the case within 60 days of the first hearing. The court, to establish the offence by the Respondent can use the sole testimony of the aggrieved person. Upon finding the complaint genuine, the court can pass a Protection Order, which shall remain in force till the aggrieved person applies for discharge. If upon receipt of an application from the aggrieved person, the Magistrate is satisfied that the circumstances so require, he may alter, modify or revoke an order after recording the reasons in writing. A complaint can also be filed under Section 498 A of the Indian Penal Code, which defines the offence of matrimonial cruelty and prescribes the punishment for the husband of a woman or his relative who subjects her to cruelty.

In-charge of Shelter Homes: The person in charge of a shelter home shall provide shelter to the aggrieved person in the shelter home upon request made by the aggrieved person, a Protection Officer or a Service Provider on her behalf.

PENALTY/PUNISHMENT • For Respondent: The breach of Protection Order or interim protection order by the Respondent is a cognizable and nonbailable offence. It is punishable with imprisonment for a term, which may extend to one year or with fine up to twenty thousand rupees or with both. He can also be tried for offences under the Indian Penal Code and the Dowry Prohibition Act. • For Protection Officer: If he fails or does not discharge his duties as directed by the Magistrate without any sufficient cause, he will be liable for having committed an offence under the Act with similar punishment. However, he cannot be penalised without the prior sanction of the state government. Moreover, the law protects him for all actions taken by him in good faith.

In-charge of Medical Facilities: The person in charge of a medical facility shall provide medical aid to the aggrieved person upon request made by the aggrieved person, a Protection Officer or a Service Provider on her behalf.

APPEAL An appeal can be made to the Court of Session against any order passed by the Magistrate within 30 days from the date of the order being served on either of the parties.

Central and State Governments: Such governments are under a duty to ensure wide publicity of the provisions of this Act through all forms of public media at regular intervals, to provide awareness and training to all officers of the government, and to coordinate the services provided by all Ministries and various Departments.

THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE RULES, 2005 The Act empowers the Central Government to make rules for carrying out the provisions of the Act. In exercise of this power the Central Government has issued the Protection of Women from Domestic Violence Rules 2005 relating to the following matters: • The qualifications and experience to be possessed by a Protection Officer and the terms and conditions of his service; • The form and manner in which a domestic incident report may be made;

Counsellors: The Magistrate may appoint any member of a Service Provider who possesses the prescribed qualifications and experience in counseling, for assisting the parties during the proceedings. Welfare experts: The Magistrate can appoint them for assisting him in discharging his functions.

PROCEDURE OF FILING COMPLAINT AND THE COURTS DUTY • The aggrieved person or any other witness of the offence on her behalf can approach a Police Officer, Protection

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Service Providers: These refer to organisations and institutions working for women’s rights, which are recognised under the Companies Act or the Societies Registration Act. They must be registered with the state government to record the Domestic Incident Report and to help the aggrieved person in medical examination. It is their duty to approach and advise the aggrieved person of her rights under the law and assist her in initiating the required legal proceedings or taking appropriate protective measures to remedy the situation. The law protects them for all actions done in good faith and no legal proceedings can be initiated against them for the proper exercise of their powers under the Act.

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• The form and the manner in which an application for Protection Order may be made to the Magistrate; • The form in which an application for legal aid and services shall be made; • The other duties to be performed by the Protection Officer; • The rules regulating registration of Service Providers; • The means of serving notices; • The rules regarding counseling and procedure to be followed by a Counsellor; • The rules regarding shelter and medical assistance to the aggrieved person; • The rules regarding breach of Protection Orders. DOMESTIC VIOLENCE AND LAW—GLOBAL SCENARIO Despite its widespread occurrence, most domestic violence is largely unrecognised or ignored by professionals, including physicians, family therapists, psychotherapists, and law enforcement officials. Importantly, health care professionals can play a crucial role in the diagnosis, treatment, and referral of victims, helping to break the often intergenerational cycle of domestic violence. Physicians can screen, assess, and intervene efficiently and effectively by eliciting a history of violence, asking specific questions when battering is suspected, documenting the physical findings that often accompany domestic violence, assessing the victim’s immediate and future safety, and communicating to the victim all realistic options. Globally, a few countries such as in USA have enacted law against this crime. Law specifically requires medical staff to report suspected domestic violence. However, many experts suggest that it is “absolutely contraindicated” to report on cases of domestic violence to any agency or authority without the victim’s direct request and consent. These experts believe that mandatory reporting of domestic violence often increases the survivor’s sense of powerlessness and may increase the risk of further harm, including the risk of homicide.15 Medicolegal Aspects: In all US jurisdictions the victim of domestic violence can obtain by statute a Civil Protection Order (CPO).16 In most of the countries an abused adult can file on his or her own behalf. An adult also can file on behalf of a child or decision-incapable adult. A few states in USA allow minors also to petition for protection on their own behalf. Persons most likely to experience domestic violence include: • Women who are single or who have recently separated or divorced • Women who have recently sough an order of protection • Women who are younger than 28 years of age • Women who abuse alcohol or other drugs • Women who are pregnant • Women whose partners are excessively jealous or possessive • Women who have witnessed or experienced physical or sexual abuse as children • Women whose partners have witnessed or experienced physical or sexual abuse as children. Despite its widespread occurrence, most domestic violence is largely unrecognised or ignored by professionals, including physicians, family therapists, psychotherapists, and law enforcement officials. Importantly, health care professionals

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can play a crucial role in the diagnosis, treatment, and referral of victims, helping to break the often intergenerational cycle of domestic violence. Physicians can screen, assess, and intervene efficiently and effectively by eliciting a history of violence, asking specific questions when battering is suspected, documenting the physical findings that often accompany domestic violence, assessing the victim’s immediate and future safety, and communicating to the victim all realistic options. A few states have enacted. Though law specifically require medical staff to report suspected domestic violence. But many experts suggest that it is “absolutely contraindicates” to report cases of domestic violence to any agency or authority without the victim’s direct request and consent. These experts believe that mandatory reporting of domestic violence often increases the survivor’s sense of powerlessness and may increase the risk of further harm, including the risk of homicide. A recent survey of physician attitudes found that “45 per cent of clinicians never or seldom asked about domestic violence when examining injured patients”. The result is less than 15 per cent of female patients report being asked about abuse by doctors or telling their doctors about their abuse.11 Basic for Granting In USA, the State laws define the relationships that must exist between the parties before a CPO will be granted. Recognised targets of a CPO include current or former spouses, family members who are related by blood or marriage, current or former household members. Courts and legislatures have identified several types of acts as abuse sufficient to support the issuance of a CPO. Acts of abuse against the petitioner include threats, interference with personal liberty, harassment, stalking, emotional abuse, attempts to inflict harm, sexual assault, marital rape, assault and battery, burglary, criminal trespass, kidnapping, and damage to property (including pets). Contents CPOs typically require that the respondent shall: 1. Not molest, assault, harass, or in any manner threaten or physically abuse the petitioner and/or his/her child(ren). 2. Stay 150 yards away from the petitioner’s home, person, workplace, children, place or worship and day care provided. 3. Not contact petitioner and/or his/her children in any manner (personally, in writing, by mail or telephone, or through third parties). 4. Vacate the residence at (location) by (date and time) (the police department shall stand by and shall give respondent 15 minutes to collect his or her personal belongings, which include clothes, toiletries, and one set of sheets and pillowcases; no other property may be removed from the premises without petitioner’s permission; the police shall take all keys and garage openers from respondent, check to see that they are the right ones, and then turn keys over to the petitioner). 5. Relinquish possession and/or use of the following personal property as of (date and time). 6. Turn over to the police any and all weapons that the respondent owns or possesses and all licenses the

8. 9. 10. 11.

Enforcement In the majority of states, violation of a CPO is a crime for which the police can arrest the offender, even if the violation did not occur in the presence of the officer. The statutory trend is to augment civil or criminal contempt enforcement with misdemeanor charges and to heighten the criminal classification for violation of a CPO. CPOs can and do remain in effect despite the parties reunification or the petitioner’s invitation to the abuser to enter her residence. Criminal Domestic Violence Prosecutions For most of the twentieth century, victims of repeated acts of domestic violence who killed their partners could not prove self-defense because courts believed that the attack was not necessary, the use of deadly force was excessive, and the victim was the aggressor in the events immediately preceding the killing. In the 1970’s, however, psychologist Lenore Walker studied several hundred women in an effort to explain the psychological and behavioral patterns that commonly appear in women who have been physically and psychologically abused by an intimate partner over an extended period. Analogising to scientific research on dogs. Walker theorised that the experience of repeated and unpreventable abuse, along with the social conditioning of women to be subservient, created in battered women a state of “psychological paralysis” that rendered them unable to seek escape or help, even when it might be available. Walker coined the term battered woman syndrome, which soon provided the basis for expert testimony designed to convince a jury that the defendant reasonably believed she had to kill to save herself, even during ebb in violence. Invoking the syndrome, however, may not always advance justice for battered women who kill. Experts therefore have encouraged a redefinition of the “battered woman” because testimony concerning the experiences of battered women refers to more than their psychological reactions to violence and because battered women’s diverse psychological realities are not limited to one particular “profile”. As the debate over the proper role of domestic violence exper t testimony continues in the legal and scientific literature, courts have begun to admit behavioural science evidence in domestic violence cases. The role of law in domestic violence cases extends beyond CPOs and criminal prosecutions. Children must be supported, as well as protected; the rights and benefits of employment must be maintained; tort actions may be appropriate; and the validity of prenuptial agreements may be imperiled.

Batterers often assault their children with increase of abuse and kidnapping. The physical and emotional consequences for children who experience domestic violence include medical problems, substance abuse, suicide attempts, eating disorders, nightmares, fear of being hurt, loneliness, bed wetting, and delinquent behaviour such as fighting, prostitution, truancy, crimes against other people, running away, dropping out of school, teenage pregnancy, cognitive disorders, and low selfesteem. Prenuptial Agreements Domestic violence may influence prenuptial agreements in three ways. First, battering may provide a defense to the enforcement of an otherwise valid prenuptial agreement. Second, domestic violence may give rise to tort claims that may offset preclusions of equitable economic distribution found in many prenuptial agreements. Third, a prenuptial agreement can include a provision that the occurrence of domestic violence invalidates the terms of the contract. Employment Issues Many victims of domestic violence are harassed at work by their former or current spouses or partners. Victims also may miss work because of injuries, court dates, or the need to cooperate with criminal investigations. Job performance may be undermined by depression, fear, and other psychological effects of battering. Employers may incur liability if domestic violence occurs in the workplace or if they fail to respond properly. Theories of liability may include the Occupational Safety and Health Administration’s “general duty” clause, respondent superior, duty to warn, wrongful discharge in violation of public policy or an employee’s privacy rights, and negligent hiring, retention, security, and/or supervision. Employees who are victims of domestic violence also are protected by workers’ compensation statutes, unemployment insurance or benefit laws, and statutes that preserve benefits for persons cooperating with the judicial process. Perhaps the biggest challenge for employers dealing with domestic violence is to balance employer interests in protecting employees and ensuring workplace safety with employee interests in privacy and freedom from defamation and discrimination.

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7.

respondent has authorising the possession of or purchase of weapons. Participate in and successfully complete a counseling program. Relinquish custody of minor children to petitioner until further order of the court or the expiration date of the order. Have rights of visitation with minor child (ren) under specified conditions. Pay spousal and child support as designated. Pay for specified repairs, medical or health insurance costs, attorney’s fees, and court costs.

CONCLUSION All medical and legal professionals must improve their abilities to identify and confront domestic violence. Appropriate and effective recognition and intervention require vigilance, knowledge of and a willingness to ask the right questions, and a sense of obligation to help society end this undesirable phenomenon. Knowledge of legal considerations should improve the collaboration of health care workers, legal professionals, and community programs seeking to control domestic violence – a major public health problem. REFERENCES 1. Source: Helpline, Retrieved on 21 May 2009, About Helplinelaw.com; http://www.helplinelaw.com/docs/violence.php. 2. Brookoff D, O’Brien KK, Cook CS, et al. Characteristics of Participants in Domestic Violence. Assessment at the Scene of Domestic Assault. JAMA 1997;277(17):1369-73.

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3. Zink T, Elder N, Jacobson J, Klostermann B. Medical Management of Intimate Partner Violence Considering the Stages of Change: Precontemplation and Contemplation. Ann Fam Med 2004;2(3):231-9. 4. Kimberly A Tyler, Lisa A Melander, HarmoniJoie Noël. Bidirectional Partner Violence Among Homeless Young Adults- Risk Factors and Outcomes, Journal of Interpersonal Violence 2009;24(6): 1014-35. 5. US Preventive Services Task Force: Screening For Family and Intimate Partner Violence: Recommendation Statement. Ann Fam Med 2004;2(2):156-60. 6. Daniel Jay Sonkin, Defining Psychological Maltreatment in Domestic Violence Perpetrator Treatment Programs: Multiple Perspectives. Source: Retrieved on 21 May, 2009; http:// www.daniel-sonkin.com/PsychAb.html 7. US Department of Justice. Cyberstalking: A New Challenge for Law Enforcement and Industry — A Report from the Attorney General to the Vice President. Washington, DC, U.S. Department of Justice, pp. 2, 6, August 1999. 8. Riveira, Diane. “Internet Crimes Against Women,” Sexual Assault Report, 4 (1), September/October 2000.

9. Wired Patrol. “US Federal Laws- Cyberstalking.” Retrieved on 21 May 2009. http://www.ovw.usdoj.gov/ 10. CJ Newton. Domestic violence: an overview, Mental Health Journal. February, 2001. 11. Rodriguez M, Bauer H, McLoughlin E, K Grumbach. Screening and Intervention for Intimate Partner Abuse: Practices and Attitudes of Primary Care Physicians. JAMA 1999;282:468-74. 12. Osofsky J. The Impact of Violence on Children. The Future of Children: Domestic Violence and Children 1999;9(3):33-49. 13. Sugg N, Thompson R, Thompson D, Maiuro R, F Rivara. Domestic violence and primary care: attitudes, practices, and beliefs. Archives of Family Medicine 1999;8:301-6. 14. Wolfe D, P Jaffe. Emerging Strategies in the Prevention of Domestic Violence. The Future of Children: Domestic Violence and Children; 1999;9(3):133-44. 15. Bostock DJ, Brewster AL. Intimate partner sexual violence. Clinics in Family Practice 2003;5(1):145. 16. Domestic Violence-Civil Protection Order; Retrieved on 21 May 2009; Source: http://www.formsworkflow.com/b_16_376_1439_ 1581.aspx.

Torture and medical profession have been closely linked for centuries. Fifty years ago in Nuremberg, Germany, 23 physicians and scientists stood trial for war crimes committed before and during the Second World War. They were accused of inflicting a range of vile and lethal procedures on vulnerable populations and inmates of concentration camps from 1933-45. Fifteen of the twenty accused were found guilty after the trials and of these fifteen, seven were given the death penalty and the remaining were imprisoned.1 In cases of state sponsored torture some doctors who have been employed by the Governments are known to have connived with the perpetrators in torturing the victims. The role of physicians in the Nazi horrors has been well documented. Doctors have been present to revive victims in instances where interrogators have been torturing their victims. Doctors have advised torturers on the victims’ weak points, and advised against any torture that would result in an ‘embarrassing’ death.2 Of course doctors could always write a false report if the prisoner did die. The Ethics Committee of the Turkish Medical Association in 1995 has suspended ten doctors for preparing false reports to hide the torture of some teenagers.3 If human rights are to be integrated into agenda, and meet the complex challenges, health professional accountability becomes a key and non-negotiable objective.4 Accountability in the context of a human rights framework is the only effective and coherent way to move beyond lip-service to effect systemic transformation and to ensure that struggle to attain socioeconomic rights can integrate health and human rights in a common paradigm.5 There were five-core objectives suggested by Baldwin-Ragaven et al in 1999.2 These are: 1. To achieve accountability to our patient and society. 2. Capacity to recognize human rights abuse when it happens. 3. To recognize and empower vulnerable groups so that all patients are treated with dignity and respect. 4. Health professionals to re-orient their practice towards larger social and political context. 5. Health professionals need to be aware of their own positioning in the society and how their values and loyalties may put them in an inconsistent or conflicting situation.6 Man has known torture since time immemorial. It is a deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons on another as punishment or to extract information. It occurs in three forms: Physical, mental and or sexual.7 About 1 in 15 asylum seekers in the United States reported history of torture. From many studies it has been ascertained that 5-30 per cent asylum seekers are tortured.8

There is a growing evidence for widespread use of torture among political prisoners throughout the world. Physicians themselves may become victims of torture when the state attempts to subvert the doctor-patient relationship, for political purpose.9 The UN Convention against torture, adopted in 1984, is one of the least ratified major human rights treaties. Only 119 States had ratified the Convention by mid-2000. Majority of the doctors in India are aware of various national and international human rights institutions, but seem not to be aware of the human rights of the detainees. It is interesting to note that the doctors are aware of the long-term physical and psychological effects of torture and also agreed that physical examination is not sufficient to detect torture sequelae. A small number of doctors expressed their unwillingness to get involved in the treatment of the victims of torture due to medicolegal consequences.9 The lack of knowledge among undergraduate and postgraduate students regarding torture led to incompetence in dealing with these cases. Medical association should take the responsibilities of protecting the doctors who fearlessly testify cases of torture besides disciplining doctors who facilitate torture. Medical profession can no longer ignore the medicolegal and ethical problems. The skills of doctors with forensic expertise allow detection of human rights abuses and thereby its potential reduction. There is scope for the reduction of torture or ill treatment; the profession maintains high standards of medical practice and ethics.10 As members of the medical profession, a physician has an obligation to their peers around the world. The current state of physicians’ involvement in the prevention of international torture and in the treatment of its victims is very important.11 In the time of electronic communication, it is easy to communicate with the relevant professionals through out the world.

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DEFINITION OF TORTURE There is a need for a comprehensive definition of torture: As per the United Nations (UN) Convention against torture, Article 1: ‘Torture’ means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as: • Obtaining from him or a third person information or a confession, • Punishing him for an act he or a third person has committed or is suspected of having committed, or 345

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• Intimidating or coercing him or a third person, or for any reason based on discrimination of any kind; when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. In the year 1975, the World Medical Association adopted a declaration against torture and called it as Declaration of Tokyo. According to this, torture is defined as: ‘A deliberate, systemic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority to force another person to yield information, to make a confession/for any other reason.12 The declaration clearly expressed that a doctor must in no way, for any reason, take part in the practice of torture or other form of cruel, inhuman or degrading procedures as the doctor’s role is to alleviate the distress of his/her fellow persons and, ‘no motive whether personal, collective or political shall prevail against this higher purpose’. METHODS OF TORTURE Beating is by far the most common method of torture and ill treatment used by state officials today. Thus the torture methods often resorted are of three types: • Physical torture • Psychological torture • Sexual torture. Physical Torture People are being brutalised and wrecked physically by various state agents to achieve one purpose or another. The method of physical torture is those, which inflict pain, discomfort in different parts of the body. Killing the victims is not the aim most of the time. The torturer also takes care that the torture inflicted upon the victim remains undetected by an ordinary examination. Therefore, torturers are trained to torture in such a way that these two precautions are well taken care of. However, despite all precautions, physical torture always leaves behind some clues that ultimately lead investigators to its discovery and to the criminals.13 Further it is noted that purpose of torture is to spread terror in the society or a country, to destroy a personality, to take revenge; and to get testimony incriminating others.12

Case Example The police arrested Mr. M on 30th July 1996.15 He was tortured by the helicopter technique (Fig. 25.1A), i.e. putting a rod between tied hands, leg together and then spinning around the rod for an hour. He was taken to courts on 2nd August 1996 for an application to be seen by a doctor. Mr. M was taken to a doctor on the 6th and released. On the 14th he was taken back to hospital with a complaint of chest pain, given a cough syrup, antibiotic and a bronchodilator and sent home. He died the following day. A doctor was appointed by the Independent Complaints Directorate to carry out the postmortem. A saddle pulmonary thromboembolus was detected. The case was referred to the author for an expert opinion regarding the possibility of death by thromboembolism two weeks after the torture 14 (Figs 25.1B and C). Types of Physical Torture Bearing in mind the methods in practice in India12 and those adopted globally, various techniques involved in physical torture are: 346

• Asphyxial torture – This is usually done by suffocating the individual. • Beating – Using rods, sticks, chains, cables or such other objects beating is done on various parts of the body from head to toe, including genitals. Method of suspending a person and beating him on the soles called Falanga, is quite popular in India. • Cold torture – Pouring thin stream of ice cold water on the nude body or sensitive parts of the body, making the person stand on or walk bare footed or lie down on the ice block, or locking naked in an extremely cold air conditioned room are some of the techniques adopted here. • Ear torture – This comprises of hitting the ears with open palm (telefona12), continuously, which will create rupture of the ear drum/tympanic membrane, causing severe pain and bleeding from ear resulting in deafness. • Electrical torture – Applying electrical shock by electrodes over the sensitive parts of such as nipples, genitals, oral cavity, anal canal, and arm pits, etc. • Heat torture – Burning by means of cigarette butts, cigar, hot iron rod or flames over the sensitive and concealed parts of the body • Irritant torture – Here an irritant like chilly paste/ powder, Tiger Balm of Rajkot,12 etc. is applied to the eyes or to other delicate parts of the body especially genitalia. They may be placed forcibly into the mouth or introduced into the anal canal, vagina, etc. The torture method may include making a person walk bare feet or lie down on broken glass pieces, thorny plants, or on pointed nails projecting up. • Keeping a person in abnormal position – The abnormal position could be in standing or sitting or lying supine or prone or on one side or crouched with tying of hands and feet also. • Mutilation – this is an extreme degree of torture where in multiple injuries are inflicted resulting in mutilation of the parts of the body or totally difficulty in establishing the identity of the person. • Pulling and/twisting of nails/hairs/tongue/teeth/ breasts/genitalia, etc – This is quite a painful procedure and may be practiced alone or together in combined form. • Roller torture – Comprises of applying roller over the parts of the body. • Suspension – Here a person is suspended either by hands/ feet for several minutes to hours. Psychological Torture Various techniques of psychological torture may be enumerated as:12 • The deprivation technique • The coercion technique • The communication technique The deprivation technique – This include social deprivation, sensory deprivation, perceptual deprivation, sleep deprivation, nutritional deprivation, hygienic deprivation and health service deprivation. The coercion technique – Impossible choice/incongruent action, humiliations, threats, blind obedience of rules and sexual torture are some of the types under this category. The communication technique – Counter-effect technique, double blinding technique, disinformation, and distortion of perception and conditioning of new reflexes.

Chapter 25: Torture and Medical Profession Figs 25.1A to E: Physical and sexual torture: (A) Torture by helicopter technique; (B and C) Autopsy findings in same victim as in A; (D) Torture by sexual assault followed by homicide; (E) Forced to drink poison and allowed to die—body recovered in partially decomposed state

Sexual Torture Sexual torture includes rape, penetration of vagina/ anus by long neck bottles, wooden or metal rods, dildos/ artificial phallus, or such other objects, which can result in injuries or mutilation of the genitalia, causing impotence consequently.12

Rape—Throughout history rape has been one of the most common but least documented acts of torture. Yet it has been an inescapable aspect of many conflicts, from the rape of the Sabine women in Ancient Rome to the allegations that the Serbs set up ‘rape camps’ during the recent war in Bosnia. 347

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Rape is a deliberate weapon, and officially sanctioned by some of the countries during wartime. More recently, Pakistani troops were alleged to have raped 200,000 Bengali women during the battle for Bangladeshi independence in 1971.27 Mutilation of the female genital—Female genital mutilation is a common and popular practice in some of the African countries, and Egypt. Thousands of young girls are subjected to this torture and mutilation in Egypt alone. Religious institutions and ancient social customs are primarily responsible for the genital mutilation of female children. The full social and psychological consequences of mutilating the genitals of female children have yet to be evaluated. Preliminary evidence, however, suggest that the psychological consequences of female genital mutilation is very similar to that of rape victims.28 Two hundred and eighty three torture victims were questioned about methods of torture and subsequent difficulties. Overall, the prevalence of sexual torture was 80 per cent in women and 56 per cent in men.29 There are indications that sexual torture has a greater impact on the development of sexual dysfunction in comparison to the other types of torture.29 For both men and women the dominant subsequent emotion is usually deep shame. Their community and family as having been defiled and no longer being fit to be accepted.30-31 Some may have been placed at risk of HIV as a result of sexual violation; particularly as in many countries the incidence of HIV is higher among soldiers, who are often the perpetrators of sexual violence. Victims may not voice their concerns about the possibility of HIV infection because of fears about confidentiality and stigma. It is important to offer testing for sexually transmitted infection and, if appropriate, for pregnancy.32 Gender bias torture especially sexual harassment of women at the work place is now a hard reality. This is the ultimate form of control especially in a position of authority. The fear of loss of job, hostility at work and social stigma still prevent women from complaining about sexual harassment.33 Post-traumatic stress disorder (PTSD) is more common in the rapes especially by strangers, of physical force being used, of weapon being displayed and injuries being sustained by the victim. These above features can readily lead to the victims developing long-term psychological sequelae after rape.34 Clinician should not focus exclusively on the amelioration of symptoms but should provide support, validation, and empowerment for sexual assault survivors who seek treatment.35 There is a significant proportion of homicide associated with sexual offences. Women are at high risk of being threatened or shot with firearms.36 There is a case of decapitation with sexual assault (Figs 25.1D). The perpetrator had sex with a girl and then beheaded her. In the examination of victims of rape, three things have to be taken into consideration by a medical officer. Firstly, the over all well-being of the victim. This is important in the sense that there should not be a life-threatening situation such as profuse bleeding that will lead to death. Rape is an acute genital injury syndrome, and need a medical officer to carry out careful examination in a holistic way. Most of the doctors are working like genital technicians only to complete the form. Secondly, the medicolegal management. This is to carry out the collection of all the evidence so that perpetrator could be brought to books. The third aim of the examination to look after the future consequences related to rape such as pregnancy, HIV infection

and other genital infections. Appropriate antibiotics should be prescribed; HIV test counseling and testing followed by antiretroviral treatment if available should be administered. Psychotherapy and rehabilitation of patient with follow up is a necessary step for the well being of the patient and their families. PHARMACOLOGICAL TORTURE This involves introduction/ feeding of various types of pharmacological substances or chemicals into the body producing repulsive symptoms.12 There is a need of medical and scientific knowledge on the use of drugs in the techniques of torture. Doctors have been involved in training perpetrators on the use of drugs. Case Examples • A well-publicised case is that of Dr Wouter Basson, who has now been struck off the medical register and is on trial. He is a cardiologist who has been nicknamed, “Doctor Death” and spearheaded the apartheid government’s germ and chemical warfare campaign. In one documented case Dr Basson supplied pharmacological agents to security forces who then injected them to their selected victims and when they were knocked unconscious, they were airlifted and the bodies thrown into the sea.2 • In 1997, a former policeman Eugene de Kock, known by his colleagues as Prime Evil, was sentenced to 262 years in jail for scores of killings carried out for the apartheid government.2 • In 1999, 5 Lesotho nationals identified as rustlers were abducted. They were then forced to drink a poison. Four died at the scene and one was admitted to the local hospital that passed away later. The four bodies were in an advanced state of decomposition when discovered (Fig. 25.1E). • In the years 1994 and 1995, representatives of physicians for human rights studied the problem of physician complicity in torture in Turkey. The research consisted of a survey of forensic documentation of torture, interviews with individual physicians who examine detainees, analyses of official medical reports of detainees, and interviews with survivors of torture. The report provided evidence that torture of political and criminal detainees continues to occur in Turkey and that Turkish physicians are coercive to ignore, misrepresent, and omit evidence of torture in their examinations of detainees to certify that there are no signs of torture. Sequelae of Torture Torture is one of the most important preventable causes of psychological morbidity. Although a great deal has been written about the history and the methods of torture, and survivors have produced moving testimonies, there is still no adequate framework within which to describe the range of psychological reactions reported. There have been attempts made to describe a single ‘torture syndrome’16-20 but these are generally unconvincing. They lack a theoretical basis and appear to be no more than a list of symptoms commonly seen in survivors of torture. These include impaired memory and concentration, headache, anxiety, depression, sleeplessness and /or sleep with nightmares and other intrusive phenomena, emotional numbing, sexual disturbances, rage, social withdrawal, lack of energy, apathy, and helplessness.18,19,21

Management of Torture Victims This comprises of diagnosis, treatment and rehabilitation. Proper history, physical examination and investigations may help in the diagnosis. The medical man may have to use special skills and diagnostic tools like bone scintigraphy. The fundamental principles for treating the victims are – avoid reminding the patient that he is the victim of torture. Both the patient and the family are to be provided with both physical and psychological treatment simultaneously. The United Nations Convention calls for education of all doctors and other health personnel. Education should therefore be at the undergraduate level and should provide an insight into torture methods, the goal and objectives of torture and the sequelae of torture so that doctors can identify victims of torture. The main principles of treatment must also be taught.23 Mental disorders figure among the leading causes of disease and disability in the world. Depressive disorders are already the fourth leading cause of the global disease burden. They are expected to rank second by 2020, following ischaemic heart disease but ahead of all other diseases. Therefore, a medical practitioner should understand not only the physical life event in its own right, but also the psychosocial problem. Society often regards persons with mental disorder as a threat rather than as a person in need of care.24 Soon after the release from torture cell, it is important to consult a psychologist for therapy. Truth and Reconciliation Commission (TRC) notes that, the conditions in mental institutions in South Africa were horrendous and did nothing to foster mental health. Inmates were used as sources of income-producing labor and there are allegations that black patients were used as ‘guinea pigs’ in research.2 More than 40 per cent of countries have no mental health policy: over 30 per cent have no mental health program; around 25 per cent of countries have no mental health legislation. The magnitude of the mental health burden is not matched by the size and effectiveness of the response it demands. More than 33 per cent of countries allocate less than 1 per cent of their total health budgets to mental health, with another 33 per cent spending just 1 per cent of their total health budgets on mental health.24

The United Nations health agency report (new understanding, New Hope) seeks to break this vicious cycle and urges governments to seek solutions for mental health that are already available and affordable. Governments should move away from large mental institutions and towards community healthcare and the general healthcare system (WHO).25 Prolonged detention without trial has serious effects on mental health of the detainees. It has been equated to psychological torture. The families of detainees too suffer. The prison health services are not adequate. Discrimination against mentally ill is thought to arise in part from the perception that they are dangerous.26 Medicolegal and Ethical Aspects of Torture

Torture and Human Rights International human rights treaties not only regulate the conduct of states and set limits on the exercise of state power; they also take action to prevent abuses of human rights. States have a duty under international law to take positive measures to prohibit and prevent torture and to respond to instances of torture, regardless of where the torture takes place and whether the perpetrator is an agent of the state or a private individual. Torture is not an intractable social problem or an inevitable part of the human condition. One can do much to address and prevent it. The world has not yet fully measured the size of the torture and does not yet have all the tools to carry it out. But the global knowledge is growing and much useful experience has already been gained. Human rights standards have been established regarding the health professional’s role in torture and participation in the death penalty.

Chapter 25: Torture and Medical Profession

Torture by definition creates a severe form of psychosomatic distress because of the person’s lack of control over the basic bodily function.22 Usually torture sequelae are a combination of physical, psychological and social events.12 The physical form comprises of severe pain, hemorrhage, infection, scars, mutilation of parts of the body, disfiguration, un-united or mal-united fractures, impairment of vision and hearing, muscle atrophy, closed compartment syndrome, chronic pain, vertigo, STD/HIV, and vague somatic symptoms. Anxiety, depression, phobia, sleep disturbance, headache, and post-traumatic stress disorders (PTSD), psychosexual problem, psychosomatic problems, and convulsion, psychotic disorders, suicidal tendencies and personality changes, are some of the psychological sequelae. The social sequelae are seen in the form of social stigma, difficulty in getting employment or loss of job, rejection by the family or society or the community.

Torture and Forensic Experts More general standards for forensic evaluations, however, are needed. The judgments of the forensic medical evaluator must be completely independent of influence by the state or third parties. The single most important threat to the human rights of individuals comes from forensic medical examiner that frames medical judgment to serve state or powerful third party interest. The forensic medical examiner should disclose the confidential report to proper authority and it is for the benefit of that individual. There is a need of checks and balances for the state-run organisations. A body of health and human rights should be established, consisting of health care professionals, human rights experts, consumers’ representatives and legal experts. It should be independent of government, professional organisations and statutory councils. In conclusion, the job of forensic professionals is to document, obtain, preserve or interpret evidence. Health professionals are often called upon to engage in evaluations for courts. In torture cases, forensic health professionals are asked to evaluate whether a person is tortured or not. It is a difficult task and risky in some of the states to be a whistle blower. There exists an inevitable tension between the roles of a forensic expert who has evaluated a torture victim to retain loyalty to the individual. 349

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REFERENCES 1. Matiharan K. The Medical Profession and Human Rights. Website: http://www.healthlibrary.com/reading/ethics/oct98/discussi.htm. 2. Baldwin-Ragaven L, de Gruchy J, London L. An ambulance of the wrong colour. Health Professionals, Human rights and ethics in South Africa. University of Cape Town, 1999. 3. Turkish daily News June 3, 1998. 4. Annas G, Grodin M. Medicine and Human rights: reflections on the fiftieth anniversary of the doctors. Health and Human rights 1996;2(1):6-12. 5. Mann J, Gostin L, Gruskin S, Brennan T, Lazzarini Z, Fineberg H. Health and Human rights 1994;1:6-23. 6. Zwi A. The political abuse of medicine and the challenge of opposing it. Social Science and Medicine 1987;25(6): 649-57. 7. Sobti JC, Makkar SP, Agrawal P, Aggarwal P. Role of doctors in prevention of torture. J Indian Med Association 1999;97(11): 466-8. 8. Eisenman D, Keller AS, Kim G. Survivors of torture in a general medical setting. West J Medicine 2000;172:301-4. 9. Sobti JC, Chapparwal BC, Holst E. Study of knowledge, attitude and practice concerning aspects of torture. J Indian Med Assoc 2000;98(6):334-5. 10. Jandoo R. Human rights abuses and the medical profession. Forensic Science International 1987;35(4):237-47. 11. Amnesty International. Take a step to stamp out torture. Methods of torture 2000;1-115. 12. Subrahmanyam BV. Modi’s Medical Jurisprudence and Toxicology, (22nd edn), Butterworths, India. 13. Opeh R. Torture. Internet website: http://www.geocities.com/ Athens/Forum/2088/d_tort.htm 14. Tanaka H. Sudden death in acute pulmonary embolism. J cardio 1997;30(3):163. 15. Allodi F, Cowgill G. Ethical and psychiatric aspects of torture. Canadian Journal of Psychiatry 1982;27:98-102. 16. Abildgaard U, Daugaard G, Marcussen H, et al. Chronic organic psycho-syndrome in Greek torture victims. Danish Medical Bulletin 1984;31:239-42. 17. Basoglu M, Marks I. Torture; research needed into how to help those who have been tortured. British Medical Journal 1988;297:1423-4. 18. Cathcart LM, Berger P, Knazan B. Medical examination of torture victims applying for refugee status. Canadian Medical Association Journal 1979;121:179-84.

19. Chowdhury AN. Torture and mental health. J Indian Med Association 2000;98(6):320-6. 20. Sorensen B, Vesti P. Medical education for the prevention of torture. Med Educ 1990;24(5):467-9. 21. Zabow T. The recognition of human rights in mental health law. Presented in 12th national psychiatry congress. 23-27 September 2002, Cape Town. 22. News Update. Mental disorders affect one in four people. Tropical Doctor, 2002;32:187-9. 23. Steadman HJ. Critically reassessing the accuracy of public perceptions of the dangerousness of the mentally ill. J Health Social Behavior 1981;22:310-6. 24. Guardian unlimited special reports. Yugoslav forces use ancient ways to break civilian spirits. Wednesday April 14, 1999. Internet Website: http://www.guardian.co.uk/kosovo/story.html. 25. Badawi M. Epidemiology of female sexual castration in Cairo, Egypt. Presented at the First International symposium on circumcision, Anaheim, California, 1989; March 1-2. 26. Theilade LD. Sexual dysfunction in torture victims. Ugeskr Laeger 2002;164(41):4773-6. 27. Hinshelwood G. Gender-based persecution. United Nations Expert Group Meeting on Gender-based Persecution, Toronto 1997. 28. Burnett A. Guidelines for health workers providing care for Kosovan refugees. London: Medical Foundation for the Care of Vict 1999. 29. WHO. Prevention of Torture. A workshop in Geneva, 1993. 30. Pathak PR. Gender bias torture in place of work. J. Indian Med Association 1999;97(11):457-60. 31. Bownes IT, O’Gorman EC, Sayers A. Assault characteristics and posttraumatic stress disorder in rape victims. Acta Psychiatric Scand 1991;83(1): 27-30. 32. Draucker CB. Perspect Psychiatr Care 1999;35(1):18-28. 33. Jewkes R, Abrahams N. Comments on the firearms control bill submitted to the portfolio committee on safety and security 2000, South Africa. 34. Cilasun U. Torture and the participation of doctors. J Med Ethics 1991;17(suppl):21-22. 35. Iancopino V, Heisler M, Pishevar S, Kirschner RH. Physician complicity in misrepresentation and omission of evidence of torture in post detention medical examinations in Turkey. JAMA 1996;276(5):416-7. 36. Amnesty International. Broken bodies, shattered minds. Torture and ill treatment of women, 8th March 2001.

Sexual jurisprudence is a subject subdivision in forensic medicine wherein the medical knowledge is applied to derive justice in cases of sexual offences. The full spectrum of what may be deemed sexual jurisprudence, is realised only when one considers the possible permutations and combinations of an infinite variety of matters related to human sexual behavior, and their physical, physiological and psychological consequences which often pose a difficulty to the medical practitioner and the law enforcement agencies. Sexual jurisprudence deals with the medicolegal aspects of virginity, impotency, sterility, artificial insemination, pregnancy, abortion, delivery, etc. on one hand, and various types of sexual offences and sexual perversions, on the other hand. Related medical issues needing legal investigation have been discussed, to enable medical professionals to handle such situations independently and easily whenever an occasion arises. Figures 26.1A and B illustrate the normal anatomy of female genitalia and Figure 26.1C shows lithotomy position, the most convenient position to perform local examination and procedures. VIRGINITY A female is called a virgin (Virgo intacta) if she has never experienced any sexual intercourse. Signs of Virginity Principal signs of virginity are studied under (Figs 26.2A to D):1-8 a. Genital findings. b. Extragenital findings. Genital Signs Labia majora–firm, elastic, rounded and lie in close contact with each other even on full abduction of the thighs.

Chapter 26: Sexual Jurisprudence

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Labia minora—soft, elastic, small, pinkish in color, and lie in close contact being completely covered by the labia majora. Vestibule—narrow. Posterior commissure and fourchette—intact and crescentshaped (it is usually lacerated by sexual intercourse in children, and rarely in adults). Vagina—narrow and tight with rugosed pinkish wall; slitlike orifice due to the apposition of its walls and presence of hymen (rugosity of wall may be lost after childbirth). Hymen—intact and may admit hardly one finger in an adult. Extragenital Signs 1. Breast—hemispherical, firm, plump and elastic. 2. Nipples—small and usually surrounded by a small areola, pinkish in fair skinned, while dark brownish in dark skinned girls. Hymen Hymen, a membranous diaphragm at the vaginal introitus, is a thin fold (about 1 mm) of mucous membrane derived from the posterior vaginal wall, with an anterior opening. Types of Hymen Based on the shape of its opening, hymen may be classified into five types1-6 (Figs 26.3A to F). 1. Annular—with an oval central opening 2. Crescentic—with a semilunar central opening 3. Vertical—with a vertical slit like opening 4. Septate—with two lateral openings partitioned by a bridge of hymenal tissue 5. Cribriform—with multiple small openings

Figs 26.1Aand B: (A) Normal anatomy of female external and (B) internal genital organs

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• Hymen is fleshy and elastic • Hymen is thick, tough and with annular or big central opening. • Hymen is situated higher up in the vagina. Other Causes of Rupture of Hymen Besides sexual intercourse, rupture of hymen may occur under the following circumstances:1,2,4 • Accidental fall astride on a projected object. • Passing of foreign body into the vagina, e.g. sanitary pads, etc. • Masturbation. • Medical manoeuvres. • Artificial manoeuvres—Aptae viris: to make a young girl fit for sexual intercourse. • Ulceration from infectious diseases like diphtheria. Fig. 26.1C: Lithotomy position for examining external and internal genital organs

Other Variants of Hymen 1. Absence of hymen—observed as a congenital deformity. 2. Infantile—with a small central linear opening. 3. Imperforate—without any opening (Fig. 26.4). 4. Fimbriated—the free margin of the hymenal opening shows symmetrical indentations or notches placed anteriorly. 5. Ring or fringe like or marginal type—with a narrow ring or fringe or band of thick membrane all around the vaginal orifice (can easily distend during sexual intercourse without rupturing the hymen). Rupture of Hymen (Deflorated) Hymen usually gets ruptured with the first act of sexual intercourse.2,4 However in some cases hymen remains intact inspite of sexual intercourse. Such condition where hymen remains intact inspite of sexual intercourse is called False Virgin.2,4,6 It can occur under the following conditions:

Changes in the Hymen after Rupture • The ruptured hymen appears like triangular projections varying from 3 to 6 in number. • The tear usually reaches up to the base. It heals up from edges in 4 to 6 days, but torn segments will never reunite. • The torn segments gradually become thicker and smaller in size and appear as small fleshy pyramidal projections, known as carunculae hymenales (Fig. 26.5). After vaginal delivery torn segments (hymenal tags) may disappear or remain as remnants in the form of marginal attachments or as an irregular thick margin known as carunculae myrtiformes. Sometimes the normal fimbriated hymen may be mistaken for torn hymen due to sexual intercourse and should be differentiated as mentioned in Table 26.1. Hymen Examination Hymen examination is an essential step in the examination of a rape victim. It is done with a special kit called ‘hymen examination kit’ that comprises of a set of glass rods of varying sizes with a spherical bulbous expansion at one end (Fig. 26.6).

Figs 26.2A to D: Signs of virginity: (A) Extragenital: Breasts—hemispherical, firm, plump with small nipple and small areola. (B) Genital: Closely approximated labia majora, covered by pubic hairs. (C) Intact hymen. (D) Genital signs of defloration: Gaping labia majora with protrusion of labia minora in a married and parous woman

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Figs 26.3A to F: Types of hymen: (A) Crescentic/semilunar; (B) Fimbriated; (C) Annular; (D) Septate; (E) Deflorated—with two lateral lacerations; (F) Deflorated—multiple lacerations

Fig. 26.4: Imperforate hymen, with radiological confirmation. Note— the radiograph shows dilatation of the vagina filled with menstrual blood and uterus with fallopian tubes pushed up to the top of the vagina

Procedure of Examination The patient is placed in lithotomy position, labia are separated and the bulbous part of the glass rod (pre-heated to body temperature) is inserted into the posterior aspect of hymenal orifice. The bulb is gently rotated along the hymenal orifice in such a way that margin of the hymenal orifice is carefully lifted up by the bulb and examined.

Fig. 26.5: Deflorated hymen: with healed tears at 4, 7 o’clock positions, and a notch at the 6 o’clock position. Note: carunculae hymenales formation

Medicolegal Importance of Virginity The question regarding virginity will be considered in the following cases: 1. Rape 2. Defamation

Table 26.1: Differences between normal fimbriated hymen and torn hymen due to sexual intercourse Fimbriated hymen

Torn hymen

Notches are symmetrical and placed anteriorly

Notches (tear) may be single or multiple (rarely), situated in the midline posteriorly or on either side.

Notches do not extend to the vaginal wall

Notches may be tears that extend to the vaginal wall

Mucosa overlying the notches is intact without any signs of inflammation around the notches.

Mucosa overlying the notches is torn with signs of inflammation in and around the tear, if fresh

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3. Nullity of marriage 4. Divorce Defloration Defloration signifies loss of virginity. The genital and extragenital signs in a deflorated female (Fig. 26.2D) are as follows:4-10 1. Hymen—ruptured (singularly important sign of defloration). 2. Labia majora—not apposed and gaping 3. Labia minora—not covered and protruding between labia majora. 4. Vaginal canal—dilated with loss of rugosity. 5. Posterior commissure—usually ruptured 6. Breast—enlarged and flabby 7. Nipple—large and surrounded by wider areola. Medicolegal Importance of Defloration • The diagnosis of virginity is difficult and in many cases a physical examination of the genital organs may not be objective and helpful. The presence of unruptured hymen offers presumption of virginity, but is not an absolute proof.9 • A false virgin may claim that she is a true virgin.2,3 • The hymen very rarely is absent congenitally. IMPOTENCE/ERECTILE DYSFUNCTION (ED) AND STERILITY Impotence (erectile dysfunction) may be defined as inability to perform sexual intercourse. Sterility means inability to procreate. In case of male, sterility indicates inability to impregnate whereas in female, it means inability to conceive. An impotent need not be sterile and vice versa however, both conditions can coexist.1-6 Frigidity refers to a woman who fails to respond to sexual stimulation. There is lack of desire for sexual intercourse. Incidence—According to NIH, it is estimated that 15-30 million of men suffer from ED in United States population.7 Causes of Impotence They are of varied nature and vary in male and female, and are discussed separately (Figs 26.7 and 26.8):

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In Males 1. Congenital or acquired malformations such as: • Bilateral hydrocoele (Fig. 26.7). • Bilateral inguinal hernia (Fig. 26.8A). • Micropenis, (Fig. 26.8B) or complete loss or absence of penis. • Severe forms of hypospadiasis or epispadiasis (Fig. 26.8C).

Fig. 26.7: Causes of impotency in male: bilateral hydrocoele (Courtesy: Dr Udaypal Singh, KMC, Warrangal, Andhra Pradesh)

2. Age: Before puberty, boys are considered to be impotent though there is no age limit for it. It depends more on the physical development of the individual. 3. Diseases—Local and general (refer below). Causes of Sterility in Males (Figs 26.8A to E) 1. Congenital or acquired malformations • Loss or absence of both the testicles. • Cryptoorchidism • Severe forms of urethral fistula. 2. Age: Before puberty, boys are considered to be sterile though there is no age limit for it. It depends more on the physical development of the individual. 3. Diseases, which includes local and general diseases are enumerated below: Local diseases a. Elephantiasis of scrotum and penis. b. Stricture of urethra. c. Large size hydrocoele and hernia (Figs 26.7 and 26.8A). d. Diseases of testis and epididymis, e.g. tuberculosis, syphilis, atrophy of testis following mumps. e. Partial amputation of penis (Fig. 26.8E). General diseases a. Exhausting constitutional diseases like diabetes mellitus, tuberculosis, chronic nephritis, hemiplegia, paraplegia, etc. b. Hormonal imbalance and chromosomal abnormalities like Addision’s diseases, hypopituitarism, etc. c. Certain diseases of the brain and spinal cord like Tabes dorsalis, transverse myelitis, syringomyelia and injuries to the brain and spinal cord. 4. Prolong or habitual use of certain drugs such as bromide, lead, cocaine, chloral hydrate, barbiturate, Cannabis indica, Dexedrine, opium, heroin, LSD, tobacco, etc. 5. Mental or psychic causes can result in temporary impotence. This may be caused by fear, too much passion, anxiety, hypochondriasis, sense of guilt and aversion. A fear of incompetence against a very virile sexual partner may cause temporary impotence. A man may be potent with a particular woman, but impotent with another woman. This condition is called impotence quad hanc or psychological impotence.

Chapter 26: Sexual Jurisprudence Figs 26.8A to E: Causes of impotency in male: (A) Bilateral inguinal hernia (B) Micropenis (C) Hypospadias, (D) Primary syphilitic chancre, (E) Partial amputation of penis (Courtesy: Dr Udaypal Singh, KMC, Warrangal, Andhra Pradesh)

In Female 1. Congenital or acquired malformations of genital organs such as absence or atresia of vagina, absence or underdeveloped ovary or uterus, tough and imperforate hymen. 2. In addition, adhesion of vaginal wall due to diphtheria or ulcers may render sexual act impossible. Kraurosis vulva in elderly female will produce vaginismus. 3. Diseases—local diseases such as vaginitis, gonorrhea, leucorrhoea, displaced position of uterus, rectovaginal fistula, tumors of labia and vaginal canal, obstruction of fallopian tubes, diseases of the ovaries, etc. 4. Age—A girl usually attends puberty by 11 to 13 years in India when menstruation begins and achieves menopause by 45 years. In female, the reproductive period normally extends from puberty to menopause. 5. Mental or pshycological causes:8 a. Hysterical fits—in this condition, any attempt to perform sexual intercourse will result in severe fits. This may be because of hatred to male sex, fear or excessive passion. b. Vaginismus—in this condition any attempt to perform sexual intercourse results in severe spasmodic contraction

of pubococcygeus (PC) muscles, perineal muscles, vaginal canal, adductor muscles, etc. (Fig. 26.9), which in turn would never allow penile penetration. It may also result from psychological trauma following rape. Type: Recently vaginismus in classified into two types:8,9 • Primary vaginismus—refers to the experience of vaginismus with first time sexual intercourse attempted. • Secondary vaginismus—refers to the experience of vaginismus a little later in life, after a period of pain free normal sexual intercourse and typically following temporary pelvic problems. The Question of Impotence Arises under the Following Conditions1,4,6 1. Civil Cases: a. Nullity of marriage—divorce, nullity and dissolution of marriage can be legally claimed and granted on the grounds of impotence when it is present at the time of marriage and incurable or curable only by surgery to which the individual refuses to submit.

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d. Where the marriage was not consummated due to impotence or wilful refusal. e. Where the woman was pregnant by another man at the time of marriage.

Fig. 26.9: Pubococcygeus (PC) Muscles—group of female pelvic floor muscles which surround both vagina and anus. They tighten involuntarily when vaginismus is experienced

b. Adultery or any other unnatural sexual offences c. Contested paternity or legitimacy where the alleged father pleads impotence or sterility as a defence. d. Cases wherein a sterile woman brings in a suppositious child claiming right over her husband’s property, when the husband is claimed to be impotent. 2. Criminal Cases: Impotence and sterility are often put forward as a plea of defense in cases of sexual offences. a. Adultery—charges for adultery where impotence is a defense plea. b. Rape—charges for rape where impotence is a defense plea. c. Unnatural sexual offence—charges for unnatural sexual offence where impotence is a defense plea. d. Injured person claiming impotence following injury caused by negligent act of another, thus claiming for compensation. e. Blackmailing and defamation. ARTIFICIAL INSEMINATION (AI)1-6 Artificial introduction of semen into vagina, cervix or uterus to bring about pregnancy is termed Artificial Insemination (AI). Types 1. Artificial insemination homologous (AIH)—when the semen of the husband is used. 2. Artificial insemination donor (AID)—where the semen of some other person is used.

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Indications 1. When the husband is impotent but fertile. 2. When the husband’s sperm count is not up to the optimum level of fertility. 3. When husband is suffering from congenital anomalies like epispadiasis or hypospadiasis and is unable to deposit semen in the vagina. 4. Rh-incompatibility between husband and wife. 5. To avoid transmission of hereditary diseases. 6. Nullity of marriage—marriage may be nullified under the following conditions: a. When either party is under-age for marriage contract. b. When either party is already married. c. When one party is of unsound mind or mentally defective or suffering from incurable disease at the time of marriage.

Medicolegal Aspects The practice of artificial Insemination makes many infertile couples happy. It is practiced all over the world.3-6 Insemination with husband’s semen is justifiable, but AID is generally not socially accepted. There is no statutory law in India for artificial insemination as yet.5,6 Nevertheless, the national guidelines are framed by the Indian Council of Medical Research.9 The following are the legal aspects of AID:1-6 1. Adultery—the donor and the recipient cannot be held guilty of adultery in India as there is no act of sexual intercourse (Section 497 IPC). 2. Legitimacy—the father is not the actual father and as such, the child is illegitimate and cannot inherit the property. This drawback may be overcome by a statutory law mentioning that the child born through consentual artificial insemination is legitimate. 3. Nullity of marriage—AI as such is not a ground for divorce. But if it is done due to impotence, or done without the consent of the husband, it will become a ground for divorce or nullity of marriage. 4. Status of the child-a child born of AID remains illegitimate unless it is adopted. But if the parents do not declare AI, the child remains a natural child for all practical purposes. 5. There is a remote chance of incestuous relationship between the donor and the recipient’s offspring. 6. Sociological aspects—the husband may feel humiliated for his deficiency in procreation and may develop psychiatric problems. If the child is mentally retarded or physically deformed, the husband may feel resentment as he is not the actual father but is partially responsible for this deformity. Mother may become neurotic as the child belongs to her alone, but not the husband. She may also develop an obsession to know the donor whose name may not be divulged by the doctors. If the child comes to know his history of birth, he may have a great shock and may even have mental trauma. Precautions Though special precaution need not be taken for AIH, the following precautions are required to be adopted in case of AID:5-7 1. The knowledge and full consent of the donor is mandatory. Similarly, consent of the recipient wife and her husband is also necessary. 2. The identity of the donor must remain secret to the recipient and her husband. 3. The results of insemination and the names of the recipient and her husband should remain secret to the donor. 4. The donor must be mentally and physically healthy and should not have any hereditary or familial diseases. 5. The donor must not be a relative of either spouse. 6. He should be fertile and his age should not exceed 40 years. 7. The race and morphological appearance of the donor should resemble the husband of the recipient as far as possible. 8. The donor should give a written declaration that he will not claim parenthood for the child. 9. Rh-compatibility between the donor and the recipient should be tested.

SURROGATE MOTHER14,15 This is a woman who bears a child either by artificial insemination from husband of a sterile woman or by implantation of in vitro fertilised ovum at the blastocyst stage. The surrogate mother bears the child and on delivery, she hands over the child to its biological father and his wife. The practice of surrogate motherhood has been commercialised thus, raising various legal issues. At times the surrogate mother refuses to handover the baby to the biological parents; and sometimes the couple get separated or divorced before delivery thus compelling the surrogate mother to abort. Some couples prefer surrogate motherhood inspite of being fertile just for the sake of maintaining a good physical appearance. There is usually a contract for the surrogate mother not to claim guardianship of the child. Thus surrogate mother is a mother by substitute. Semen Bank Human semen can be preserved for future donation by means of slow cooling and by addition of glycerol. However, there is a legal problem when the woman becomes pregnant after the death of her husband and claims her posthumous child to be the product of insemination from the semen bank of her husband, thus demanding the child to be declared as the legal heir to her husband.16,17 STERILISATION Sterilisation is a procedure to render a person sterile but without any interference to potency or sexual function.1-6 Types 1. Compulsory: This is performed by an order of the State on eugenic grounds for those who are mentally defective and as a punishment for those sexual criminals. It is not practiced in India. 2. Voluntary: Voluntary sterilisation may be done on the following grounds: – As a family planning measure. – For therapeutic purpose—This is performed to prevent danger to the health or life of the woman by future pregnancy. It is done as a therapeutic measure for certain diseases. The indications are: a. Repeated cesarean operations. b. Chronic diseases of the heart, lungs or kidneys, or carcinoma of breast or testicles where removal of ovaries or testis is performed. c. Severe physical or mental defects. – As eugenic measure—It is also done on eugenic grounds to prevent transmission of hereditary diseases. Methods Sterilisation could be permanent or temporary. a. Permanent methods are vasectomy in male and tubectomy in female, and exposure to deep X-rays of gonads in both.

b. Temporary methods are the use of oral hormonal pills, condom, diaphragm, spermicidal jellies and intrauterine contraceptive devices including loops, copper T, etc. Legal Safeguards for Permanent Sterilisation18 The following precautions should be observed before undertaking the surgery: a. Written consent of both the couples should be taken. b. When performed for family planning purpose, the age of the husband should not be below 25 and the wife below 20 years and they must have at least two children one of whom should be a male child. c. When performed for eugenic or therapeutic purpose, a senior colleague should be consulted. d. It is preferable to have a seminal check-up after vasectomy. The couple should be advised to abstain from sexual intercourse for at least 3 months or till the semen examination shows absence of spermatozoa.

Chapter 26: Sexual Jurisprudence

TEST TUBE BABY (IN VITRO FERTILISATION/IVF) In this process, the ovum of the wife is removed from the ovary through the abdominal wall and is fertilised by the sperm of her own husband in a laboratory. At the stage of blastocyst, the developing embryo is implanted into the uterus through the uterine cervix and develops there till full term foetus. It was Dr. Steptoe who pioneered the birth of the first test tube baby in Bolton, England in mid 1970s.13

PREGNANCY Pregnancy is a phase in the reproductive period of a woman which results as a consequence of fertilisation of an ovum by a sperm. Diagnosis Pregnancy can be diagnosed from subjective and objective signs.2-6 Subjective Signs • Amenorrhea (cessation of menstruation) • Morning sickness: nausea and vomiting on getting up from bed in the morning • Perverted appetite • Increased frequency of micturition • Progressive enlargement of abdomen • Quickening—a peculiar sensation of fetal movement felt by the mother (felt from 16th week of pregnancy) • Excessive salivation • Constipation All these subjective symptoms are of mere presumptive value and not much of diagnostic significance as they can also be found in many other pathological conditions. Objective Signs They include probable signs and positive signs of pregnancy. Probable Signs a. Changes in the Vagina • The normal pink colour of vaginal mucosa changes into violet and ultimately into blue colouration due to increased vascularity resulting from pressure of the gravid uterus (Jacquemier’s or Chadwick’s sign). • Flattening of anterior vaginal wall by the upwardly titled cervix. • Thickening of hypertrophied mucosal folds. b. Changes in the Cervix • Increased vascularity imparts certain changes to the cervix such as softening (Goodel’s sign), fullness and roundedness with circular external os. c. Changes in the Uterus: The increase in the size due to the growing foetus makes it an abdominal organ from fourth month of pregnancy. The fundus of the uterus can reach the level of xyphisternum at full term (Fig. 26.10). Gestational changes in the uterus are enumerated below:

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• Pigmentation of areola, making it darker • Secondary areola formation, i.e. the pigmentary changes go beyond areola (primary areola) on the normal skin around for about 2-5 cm or more. • Superficial veins may become more distinct. • Secretion of colostrums (witch’s milk) from fourth month. e. Laboratory tests: Several laboratory tests have been reported, but each of them have their own limitations, as these tests can give positive results in conditions other than pregnancy.

Fig. 26.10: Fundal height at various weeks of gestation

• Increase in size— progressive increase in the size is observed with the growth of the fetus within. • Hegar’s sign is the characteristic softening of isthmus of the uterus, detectable by manual examination, from sixth week. • Braxton Hick’s sign is an intermittent uterine contraction, seen only after fourth month. • Uterine souffle—a blowing sound synchronous with maternal pulse, due to the blood circulation through the enlarged tortuous uterine arteries heard by auscultation of the abdomen from sixth month onwards. • Ballottement (tossing up like a ball)—by this test, the palpating hand or finger can give a jolt or push to the fetus per abdomen (external ballottement) or per vaginum (internal ballottement) only to feel the hitting back of the fetus on the palpating fingers immediately. It can be elicited positively during fourth and fifth fetal month. • Foetal part can be palpated through abdominal wall. This is appreciated only after sixth month. d. Changes in the Breast: Mammary changes are prominent in primi and they are as follows: (Fig. 26.11) • Enlarges in size, becomes firm, tense and tender. • Nipples become prominent, with 10-12 small pigmented nodules around called Montgomery’ tubercles.

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I. Biological tests: These tests are based on reactions of chorionic gonadotropins in pregnant woman’s blood or urine on test animals. These include: Asheim Zondeks test, Friedman’s test, Hogben test, etc. However, introduction of newer immunological, rapid reporting, highly sensitive tests have made the biological tests almost outdated. II. Immunological tests: These tests are based on antigenantibody reaction upon human chorionic gonadotropin hormone (HCG) passed by the pregnant mother in her urine. They are: • Gravindex slide test • Prognosticon tube test, etc. An antibody against HCG is obtained by injecting HCG into rabbit, and then collecting the serum. Sheep RBC or latex particles coated with HCG. Procedure: • A few drops of the morning urine of a pregnant woman are first treated with anti-HCG serum, and then with coated sheep RBC or latex particles. • If the urine has HCG, a reaction takes place between the HCG in urine and the anti–HCG in serum. Thus, red cells/ latex remain unagglutinated, and the test is reported as positive. • If the urine has no HCG, anti-HCG in the serum added would be available in the suspension and react with the HCG coated on sheep RBC or latex particles, producing agglutination. This is reported as negative test. • Time required for reporting 2-3 minutes. • Fallacies—false-positive results may be reported with hydatidiform mole, chorion-epithelioma, ectopic gestation, etc. Positive Signs of Pregnancy (Synonyms —Absolute/Conclusive/Certain/Sure Signs of Pregnancy): 1. Foetal movements: these are felt by keeping the palpating hand on the abdomen from fourth month and also seen by naked eye examination from fifth month.

Fig. 26.11: Breast changes in pregnancy. Note—large, soft, pendulous nature with large nipples and dark areola and Montgomery tubercles

Medicolegal Importance 1. When a woman is condemned to death or sentenced to undergo rigorous imprisonment, she might submit a petition to the court, stating that she is pregnant. In India, during pregnancy, a woman cannot be hanged, until she delivers and the child is six months old. 2. When a woman after her husband’s death may feign to be pregnant, so that she might be entitled to the estate left by her deceased husband on behalf of the prospective heir. 3. When a woman after claiming to be pregnant, brings an accusation in the court for breach of marriage or seduction against a certain person. 4. When an unmarried woman, a widow or a woman living separately from her husband, wants to get rid of charges of adultery brought against her on grounds of her pregnancy. • When a woman alleged to be pregnant asks for compensation from a person.

• When the pregnancy of a widow or an unmarried girl is suspected to be the motive of her suicide or murder. • A woman who is pregnant can claim greater compensation in case of death of her husband in a railway or aeroplane accident. • In case of attempted criminal abortion or infanticide. • Pseudocyesis (Synonyms : spurious pregnancy, phantom’s pregnancy, feigned pregnancy): This is a condition wherein a woman who has no issues nearing menopause and intensely desiring an offspring, presents with all subjective signs of pregnancy including an abdominal distension which may be due to deposition of fat, ascites or tumour. • Duration of pregnancy: Accepted average period of pregnancy is 280 days (i.e. 10 lunar months or 10 times intermenstrual period) from first day of last menstrual period (LMP). • Period of viability: Child born at or after 210 days of pregnancy is considered a viable child, as it is capable of an independent survival outside the mother’s uterus (Refer Chapter on Infanticide)

Chapter 26: Sexual Jurisprudence

2. Foetal heart sound: forms an important and definite sign of pregnancy, heard from 18 to 20 weeks. Normal heart rate is 160 per minute at fifth month and 120 per minute at ninth month. 3. Radiological diagnosis: shadow of fetal skeleton in the radiograph and ultrasound scanning of the abdomen is diagnostic of pregnancy, which is usually seen from 15th to 16th weeks. It is also diagnostic of twin pregnancy, fetal abnormalities, intrauterine death of fetus (Spalding’s sign— crowding of cranial bones) (Figs 26.12 and 26.13), hydatiform mole, etc.

DELIVERY Delivery refers to the birth of the child, on completion of 280 days of pregnancy (full term). If delivery occurs earlier than 280 days, it is called premature delivery, while if it occurs after 280 days, it is called postmature delivery. Signs of delivery: Signs of delivery could be recent or remote. It again varies in the living or in the dead.1-6 Signs of Recent Delivery in the Living Signs mentioned below are characteristic of a full term delivery other than a premature one. They are likely to disappear within 10 days in a healthy woman. General indisposition: She will be apathetic, pale, and ill-looking with slight increased pulse and body temperature.

Fig. 26.12: Spalding’s sign—ultrasound images of the foetal skull—overlap of bones—IUD of foetus

Abdomen: Abdominal wall is pendulous, lax, wrinkled with striae gravidarum. Breasts: These are full, enlarged and tender exuding colostrum or milk. The areola is dark, nipples prominent and Montgomery’s tubercles are present. Uterus: The uterine changes may be enumerated as: • 0-1 day – relaxed flabby mass at umbilical level. • 2-3 days later – hard, cricket ball-like mass in the lower abdomen. • In 6 weeks – normal. Cervix: It is soft, patulous with torn or lacerated edges. The internal os begins to close within 24 hours. External os is soft and patent; admits two fingers for a few days initially, followed by one finger at the end of one week, and complete closure in 2 weeks. However, it is transverse, enlarged and patulous in parous uterus, while in nulliparous, it is small, round and dimple like in the centre of cervix.

Fig. 26.13: Spalding sign foetal skull bones and spine and ribs overlap–IUD of foetus (Courtesy: http://myweb.Isbu.ac.uk/dirt/ museum/856-826.html)

Genital tracts: • Vulva – is swollen, may be bruised and lacerated • Labia majora – are swollen, congested and may be bruised and tender • Fourchette and perineum – may show laceration

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Table 26.2: Changes in size and weight of the uterus after delivery Days

Size (l x b x t cm)

0-1 day 2-3 days 4-7 days 8-15 days 6 weeks (Normal) l  b  t = Length  breadth  thickness

25.0 17.5 14.0 12.0 07.0

• Lochia – is a discharge from the uterus, and its presence is a characteristic sign of all recent deliveries. It has got a peculiar odor and is of three types: Lochia rubra – First 3 to 4 days, bright red in color, blood mixed, with large clots. Lochia serosa – in next 4 days it turns pale and serous. — Lochia alba – on about ninth day it turns yellowish gray or lightly greenish, gradually diminishes in quantity and then disappears completely. Signs of Recent Delivery in the Dead In addition to findings mentioned above in the living, following may be observed in the uterus: 1. Size of the uterus – it depends on how long the victim lived after delivery. Table 26.2 highlights changes in the size and weight of the uterus depending on number of days of survival of the woman after delivery. 2. Peritoneal covering is wrinkled. 3. Cut section shows – dark coloured, irregular area of placental attachment covered with blood clots. The diameter of this area can give clue about the number of days after delivery as shown in Table 26.3. 4. Fallopian tubes – congested 5. Ovaries – both are congested and one of them show a large corpus luteum. Signs of Remote Delivery in the Living Pregnancy usually leaves tell tale permanent marks on the body of the woman provided, it is a full term pregnancy. These findings are: Abdomen: Abdominal wall will be lax with linea nigra and linea ablicantes. Breasts: Will be large, soft, and pendulous, with large nipples, dark areola and Montgomery’s tubercles. Genital tract: • Vulva – gaping • Vagina – vaginal orifice is partially exposed, vagina will be capacious, and with no rugosity, and walls not approximated. • Hymen – absent or if retained seen as tags called carunculae myrtiformes. • Cervix: external os appears like transverse slit. Signs of Remote Delivery in the Dead In addition to the findings mentioned above in the living, there will be: Table 26.3: Diameter of the placental area

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Day/weeks

Diameter (cm)

0-3 days 4-7 days 6-12 weeks

12-15 03-04 01-02

    

20.0 10.0 08.0 06.0 05.0

    

10.0 05.0 05.0 02.5 02.0

Weight(gm) 1000 500 350 125 80

• Uterus – slightly enlarged with thicker walls, larger cavity and more weight. Medicolegal Importance It is necessary to determine whether the woman has delivered or not in solving the cases, such as: • Legitimacy • Legal action for disputed chastity • Feigned delivery • Abortion and infanticide • Concealment of birth • Blackmail – a woman may feign pregnancy for sometime and then produce some child, alleging that, it is her child. The motive here is to extract money by blackmailing. Such a child is called “fictitious child” or “suppositious child” • Affiliation cases – these are cases wherein woman having illicit sexual intimacy with a man may become pregnant, and deliver a child and then sue him for maintenance of the child. PATERNITY Paternity is the ‘fatherhood’ of a child. Diagnosis of Paternity Determination of paternity is usually done by certain tests and these tests are called paternity tests 1-6 such as: 1. Parental likeness – a child may resemble the parents in feature, figures, complexion, gesture, gait, colour of iris and hair, mannerism, etc. and with this we infer that the child is of such a parent. However, mere resemblance is not reliable. It is only considered to be of corroborative value. 2. Atavism – at times the child may not resemble the parents but grandparents. This is called atavism. It is also of corroborative value.19 3. Blood group tests – blood group of an individual is of a hereditary transmission origin from a parent to the offspring. Hence, determination of blood group of a child and parents is of help in establishing the paternity. Table 26.4 summarizes the possible children for specific blood group parents. 4. Determination of nonpaternity is also established if the alleged/putative father is: • Impotent or sterile • Had no access to his wife • Blood groups of the child and father are inconsistent • Racially not similar to that of child. Medicolegal Importance • In case of legitimacy and disputed paternity • In case of fictitious child • Superfecundation: This is a condition wherein fertilisation of two ova, discharged in the same ovulatory period, occurs by different acts of coitus resulting in birth of twins. If by

Blood groups of parents

Possible groups of the child

Blood groups of child not possible

O + O O + A O + B O + AB A + A A + B B + B AB + AB

O O, O, A, A, A, B, A,

A, AB, B B, AB A, AB O, AB B, AB None A, AB O

A B B O B, AB, O O B, AB

any chance the woman had coitus with two different men of different race, twins born will be of different race.1,4,6,9 • Superfoetation: this is a condition wherein fertilisation of two ova, discharged in two different ovulatory periods, occurs by two different acts of coitus, resulting in twins at birth, one of which will be always older than the other.1,4,6,9 LEGITIMACY A child born during the continuance of a legal marriage is considered a legitimate child. A child born to a couple who are not married legally is considered to be illegitimate or a bastard. Presumption in Favour of Legitimacy The law in India has accepted certain presumptions in favour of legitimacy, based on the principle that the law is averse to declare a child a bastard. These presumptions are:1-7,10-13 • Child born to a woman who is living with her legally wedded husband, but the offspring is in reality a product of her illicit intimacy with a paramour, is still considered as legitimate child, till the contrary is proved in the court. • A child born to a woman within 270 days of divorce is considered as legitimate child until the contrary is proved. • A couple indulges in sexual intimacy prior to marriage and consummation takes place. However, they get married later and the child is born soon after marriage, such child is also presumed to be legitimate until the contrary is proved (example of William Shakespeare in England). Medicolegal Importance Legitimacy may have to be decided in cases of: • Affiliations – according to the law, father of an illegitimate child, must arrange to maintain it. • Inheritance – a legitimate child alone can inherit the property • Fictitious child. SEXUAL OFFENCES Sexual offences are almost of infinite variety of physical acts by a person with another person or animal, either executed or attempted in the furtherance of sexual gratification. Classification Sexual offences are of three types:1-6 (i) Natural sexual offences, (ii) Unnatural sexual offences, and (iii) Sexual deviations or perversions (Table 26.5). Unnatural sexual offences and sexual deviations together are often referred as sexual paraphilias. Natural Sexual Offences All such physical acts executed within the order of nature’s accordance in furtherance of sexual gratification are considered as natural sexual offenses. They include: • Rape • Incest

Unnatural Sexual Offences All such physical acts executed against the order of nature’s accordance in furtherance of sexual gratification are considered as unnatural sexual offenses. They include: • Sodomy, Lesbianism, Buccal coitus, Bestiality.

Chapter 26: Sexual Jurisprudence

Table 26.4: Possible (blood groups) children for specific blood group parents

Sexual Deviations (Sexual Perversions) All such physical acts executed which are not only against the order of nature’s accordance, but also against human biology in furtherance of sexual gratification are considered as sexual deviations. They include: • Eoneism, exhibitionism, fetishism, masochism, masturbation, nymphomania, necrophagia, necrophilia, satyriasis, sadism, transvestism, troilism, undinism, voyeurism, etc. (see Table 26.5). RAPE Legal Definition A man is said to commit “rape” if he has sexual intercourse with a woman under circumstances falling under any of the six following descriptions:20,21 • First– Against her will. • Second – Without her consent. • Third – With her consent, when her consent has been obtained by putting her or any person in whom she is interested in fear of death or of hurt. • Fourth – With her consent, when the man knows that he is not her husband, and that her consent is given because she believes that he is another man to whom she is or believes herself to be lawfully married. • Fifth – With her consent, when, at the time of giving such consent, by reason of unsoundness of mind or intoxication or the administration by him personally or through another of any stupefying or unwholesome substance, she is unable Table 26.5: Sexual offences encountered routinely Natural

Unnatural

Sexual perversions

Rape Incest

Sodomy Lesbianism Buccal coitus Bestiality

Eoneism Exhibitionism Fetishism Masochism Masturbation Nymphomania Necrophagia Necrophilia Satyriasis Sadism Troilism Undinism Voyeurism

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to understand the nature and consequences of that to which she gives consent. • Sixth – With or without her consent, when she is under sixteen years of age. Explanation: Penetration is sufficient to constitute the sexual intercourse necessary to the offence of rape. Exception: Sexual intercourse by a man with his own wife, the wife not being uinder fifteen years of age, is not rape. In the Manipur State, rape law has reduced the ages of valid consent to sexual intercourse by unmarried and married woman to 14 and 13 years, respectively. Rape and Law a. Explanation of rape definition — Rape is said to have been committed when a man has sexual intercourse with a woman: • With or without her consent, when she is below the age of 16 years. • With consent when she is: — His own wife, but below the age of 15 years. — Mentally ill. • With consent when she is above 16 years but the consent is obtained by: — Fear – threatening to kill her — Fraud – pretending to be her husband — Intoxication – with intoxicating agents like alcohol. b. Rape and gender – in law, rape is an offense, which can be committed only by man. • Reasons—In sexual intercourse, man is considered to take an active role rather than a woman. c. Rape and degree of penetration – Penetration is sufficient to constitute the sexual intercourse necessary to the offence of rape. The depths of penetration, seminal emission, rupture of hymen, etc. are not considered as important factors in justifying the offense of rape. • Reasons—In a child victim actual penetration may not be accomplished due to the disproportion of the sex organs, but other injuries might have resulted due to the force used, e.g. perineal tears, contusions of the labia, etc. d. Rape and resistance – depending on the age, build, health and social status, a victim can usually offer resistance prior to the actual act resulting in marks of struggle or struggle evidence such as nail scratches, abrasions, bruises, bite marks, etc. These marks of struggle constitute good corroborative evidence in favour of rape. e. Consent for sexual intercourse – consent becomes valid only if the following criteria are fulfilled: • She must be 16 years or above by age • She must give it prior to the act • She must give it voluntarily and freely • She must be “compos mentis” and not intoxicated. Thus, even a prostitute can plead for being raped against a man who had coitus with her without her consent. f. Age and rape • Age of assailant – in Indian law, a male of any age is considered eligible for sexual intercourse (in England, male above 14 years is only deemed to be fit). • Age of victim – no age in a female is free from the fear of rape. However, child victims are often preferred by a rapist and reported frequently for the reasons such as: – They offer little resistance – They can be seduced easily

– –

They can be threatened successfully and keep the event secret For a “false belief” of curing the venereal diseases, as practiced in some remote villages in rural India even today.

Punishment for Rape Rape is a cognizable offense. IPC section 376 defines the punishment of rape.20 Whoever commits rape shall be punished with imprisonment of either description for 7 years but which may be for life or for a term which may extend to 10 years and shall be liable to fine unless the victim is his own wife and not under 12 years of age, in which case, he shall be punished with imprisonment up to 2 years or with fine or both. Dangers of Rape1-16 • Shock due to fear, may turn fatal or when the victim survives, may make her mentally deranged temporarily or permanently • Haemorrhage, due to genital injuries, may be fatal when severe • Accidental death, e.g. Suffocation – the assailant may cover his hand over her mouth and nostrils preventing the victim from shouting or screaming for help; can result in suffocation and death • Homicidal death, e.g. Strangulation – in order to conceal the event, the assailant may kill his victim after rape • Psychological trauma; parasuicide/suicide – out of frustration of being raped, the victim may end her life. EXAMINATION OF CASE OF SEXUAL ASSAULT Apart from the medical responsibilities, the duties of medical investigator include the examination of the victim (alive or dead) and the accused to gather evidence to corroborate the charges and to apply in the adjudication of the complaint. The method of performing the examination may differ from case to case; a general plan of examination consisting of examination of the scene, medical examination of the victim and the suspect or accused is discussed below:22 Examination of the Scene Although examination of the scene is primarily the responsibility of police, it will be worthwhile for a forensic pathologist to visit the crime scene personally, especially in cases where the victim is dead. Medical Examination of the Victim Avoid unnecessary delay. Examination of the victim (Figs 26.14A and B and 26.15A and B) of rape constitutes three steps (remember 3Gs): • General Procedures/Preliminaries • General Examination (Fig. 26.14A) • Genital/Local Examination (Fig. 26.14B) I. General Procedure/Preliminaries: • Requisition: Requisition for examination of the victim can be obtained from the Investigating Officer (IO) or from Judicial Authority. Examination can be carried out only after the receipt of the requisition from the concerned legal authorities. Ideally it should contain the bio data of the victim including residential address, name of the Police Station along with FIR number, identity of the escorting police, a brief history of the case and queries from the IO. • Date, time and place of examination: should be recorded. • Identity of the victim: The victim should be physically identified by the escorting police and by any

Fig. 26.14B: Examination of the victim of rape—genital findings

•

• • • •

accompanying guardian before the medical officer prior to the examination. Consent: Victim of sexual assault cannot be examined without her consent. Depending on the age of the victim, informed written consent for medical examination can be given by herself or by her guardian. The examination of the victim should always be done in presence of a female third person, e.g. nurse, female attendant. Second opinion: Never hesitate to take second opinion from a qualified person if necessary. Report all findings properly Prepare three copies: Two copies for submission and one for the office file. A sample of standard proforma of examination of a case of rape is provided in Proformas 26.1 to 26.3. History – History of the incident and post-incident events: Date, time, place of alleged occurrence, alleged suspect’s name if known, description of the alleged suspect,

Findings in a Virgin Victim All findings are described as typical findings of rape and become corroborative evidence in law and these are (Figs 26.16 and 26.17A to C): • On the vulva – redness, bruises, swellings, tears, scratches, bleeding, etc. (Figs 26.17A to C). • With the hymen – recent rupture is of maximum corroborative value. Note the site and degree of tears. Hymen examination kit should be used (see Fig. 26.6). • In the vagina – bruises, tears, bleeding, discharges (venereal origin), foreign particles, etc. (menstrual flow may be there if she is in her menstruating period).

Chapter 26: Sexual Jurisprudence

Fig. 26.14A: Examination of the victim of rape—general physical examination

detailed circumstances of the incident, drug and/or alcohol influences, damage to clothing and injuries to person. – Sexual history: Any past history of involuntary/ voluntary intercourse including date, time and place of the last act. – Medical history: Menses: If menarche, regularity, interval, duration and last menstrual period, vaginal discharge; Pregnancies; STDs, Illnesses including medical care and physician; Surgical operations including sterilisation. – Personal history: Change of clothing, Vaginal douching or taking bath after the incident; Habits: use of alcohol, drugs, etc. II. General Examination: • Examination of clothing: The victim should ideally undress herself whenever possible or otherwise assisted by the third party. The person is made to stand over a wide white paper/cloth (Catch paper/cloth) to collect any trace evidence that may dislodge while undressing (Figs 26.15A and B). – Manner and state: Disturbed, shabby, etc. – Damage: Tears, loss of buttons. – Stains: Body fluids (Blood, semen, saliva, urine, faecal matter), mud, etc. – Other trace evidence: Hairs, fibers, grass, etc. – Note the demeanour and emotional state, gait. – Collect stains and any other trace evidence present on the body adopting standard procedures (Figs 26.15A and B). – Record vital signs. – Look for presence of signs of struggle, violence which may present in any form (Fig. 26.16) such as abrasions (nail scratches), bruises, bite marks, lacerations, incised and stab wounds, etc. Any injuries present should be properly documented, incorporating sketches or photographs whenever possible, giving exact location, detailed description: size, shape, type of injury, age of injury, etc. III. Genital/Local Examination: (see Figs 26.14B; and 26.15B) Prerequisites: • Position: proper examination is possible only by making the patient adopt the lithotomy position (Fig. 26.1C). • Proper illumination: can help good observation. • Local anaesthesia: use of this may be beneficial when the victim is complaining of severe pain. • Examination proper: findings differ depending on the victim who could be a virgin, deflorated woman, or a child (Figs 26.14 to 26.22).

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Proforma 26.1: Examination of rape victim

Requisition from SI of..............................Police Station with his Letter No. ........ Dated ............... for examination of ..............................in charge of PC No. ................. 1. Name and address: 2. Age as stated by: 3. Occupation: 4. Married or not: 5. Number of children if married: 6. Persons accompanying and their relationship: 7. Consent—Obtained from parents in the case of minor girls. Always get signature. However explain that the physical findings observed during examination will be used as evidence during trial whether or not it is in his interest and he is free to refuse being examined if he chooses. 8. Nurse or other female present 9. Marks of identification 10. History as given by the police 11. History as given by parents/relatives 12. Statement of the female with regard to the following: • Date, time and place of occurrence • Exact position of the parties • Did she struggle or cry for help? • Was she menstruating or not? • Was she conscious the whole time? • Did she urinate or not? Pain? • Did she change her clothes? 13. Date and time of lodging a complaint, explain delay 14. Date and time of physical examination 15. Mental disposition. Excited or calm 16. Gait. Does she walk as if in pain? 17. Clothes—look for blood, semen, hair, tears, loss of buttons, mud, grass, etc. Describe location and extent of each. 18. Physical development—height, weight, build. 19. Marks of general violence—look for abrasions or contusions of face, back of the shoulder, arms, and thighs. 20. Breasts—look for contusion, abrasion, and bitten nipples. 21. Pubis, perineum, thighs—look for stains, matting of hair, scratches. 22. Vulva—look for bruises, abrasions 23. Hymen—present or replaced by carunculae, if present—type, position of natural opening, whether torn/intact, if torn— position, extent and age of tear. 24. Fourchette—intact/torn. 25. Vagina—look for bruises, tear, nature of discharge 26. Veneral disease—gonorrhea/syphilis—get specialist’s opinion if it is necessary and possible. 27. Vaginal smear—for spermatozoa, blood. 28. Preserve following material for chemical examination 29. Clothes are dried to prevent decomposition of stains. Put in a cardboard box, seal, and label. 30. Take vaginal fluid with a swab. Rub on two sides. One side may be examined immediately. The other one is dried well, covered with cotton and wrapped in paper, sealed and labeled. Get authorization from the investigating officer and send the materials for chemical examination.

• In the perineum—tears (especially the fourchette), scratches, bruises, etc (see Fig. 26.17C). Findings in Deflorated Woman Victim Typical findings described in the virgin victim may not be elicited in a deflorated woman victim. However, presence of the following is important in such cases: 364

• Semen in the vagina (in fornices or vulva or garments worn, confirmed by vaginal smear) (see Fig. 26.22). • Evidence of struggle is more important. Findings in a Child Victim Typical findings described in the virgin victim may not be elicited in a child victim, due to anatomical disproportion in genitals

Requisition from SI of ...............Police Station, with his Letter No ................. Dated ............. for the examination of ........................ and in charge of PC No. ............. 1. 2. 3. 4.

5.

6. 7. 8. 9. 10. 11.

12. 13.

15. 16.

Name and address Age ...............years Occupation Consent for examination obtained from (get signature) Note: Explain to the person that the physical findings observed during examination will be used as evidence during trial whether or not it is in his interest and he is free to refuse being examined if he chooses. Identification marks a. b. History as given by the Police Statement of the individual Gait Clothes (look for blood, semen, tears, mud, grass, etc.) Did he change the clothes or wash his parts? Date and time of examination Physical development (Look for any general violence on the body as bite marks, scratches, contusions, etc. indicative of resistance from the female) Pubic region and thighs (look for matting of hair, stains). Penis—look for any of the following evidence of impotence (general examination is required if he pleads impotence - as defense. a. Evidence of venereal disease (get expert’s opinion) b. Smegma (retract prepuce and see) c. Frenulum (torn/intact) d. Paraphimosis (present/not) e. Glans penis (look for abrasions) f. Foreign hair underneath the prepuce (preserve if any for comparing with pubic hair of the female). Microscopic examination of discharge Preserve clothes stained with blood and semen for chemical examination. Note: When the physical examination is over and the necessary articles have been preserved for chemical examination, a certificate is issued in either case (victim and suspect).

Chapter 26: Sexual Jurisprudence

Proforma 26.2: Examination of accused of rape charge

Fig. 26.15B: Examination of the victim of rape—specimens (trace evidence) genital

Fig. 26.15A: Examination of the victim of rape—specimens (trace evidence) general/physical

of victim and accused. However, presence of following is important in such cases:1,4,5 • Inflammation/abrasion/bruises of vulva • Inflammation of urethra • Hymen – intact/torn/destroyed

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Proforma 26.3: Report/certificate on sexual offences

Appearances found on the person of a male/female named,................... aged ..........years, an inhabitant of...................sent by SI of ....................... Police Station, with his Letter No......dated..................accompanied by PC No. .....................for examination and report for certain injuries or other findings said to have been caused of .....................................and to be due to rape/sodomy. Identification marks a. b. The person was first seen by the undersigned at.....on.......................and the examination was conducted at .......on...............when the following were found (state the essential findings)...........................................................

Station: Date:

Signature of MO Name Designation Address Rubber Stamp

Note: • It is not advisable to state whether rape had been committed or not. Medical evidence should always be analyzed in the light of circumstantial evidence and is done during trial. • The certificate is issued as soon as the examination is over. The detailed report prepared during examination is kept with the doctor and can be used for refreshing memory during trial. • As soon as the report of the chemical examination is available, it should be forwarded to the Investigating Police Officer, after recording the essential findings in our note. • When the age is disputed, determine age as directed elsewhere.

Fig. 26.16: Victim of rape. Note the struggle marks on the body of the victim

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Chapter 26: Sexual Jurisprudence Figs 26.17A to C: Genital examination findings of rape injuries in a virgin victim: (A) Redness, bruising, ecchymosis, swelling of vulva, tearing of hymen at 7 o’clock position; (B) Scratches and redness and swelling of labia minora; (C) Swelling, redness, scratches, bruise in the fourchette-perineum24 (Source: http://www.medical-library.org/journals5a/rape–pictures.htm)

• Perineal tears – uncontrolled bleeding/clotted blood. • Discharges of lesions of STD such as gonorrhea, syphilis, etc. Collection of Evidence: Rape is an excellent example for Locard’s Principle of Exchange,1,4,5 which states that every contact leaves a trace. Physical and biological evidence play a pivotal role in the objective and scientific reconstruction of the events in question. The evidence should be collected from the victim, from the crime scene and from the suspect employing standard techniques. Each sample should be packed using appropriate packaging materials, labelled, sealed and stored as per specification before transporting it to the laboratories. Documented chain of custody of the evidence should be maintained strictly at every level to ensure the authenticity of the evidence. 1. Stains and foreign materials present on the clothing or body. 2. Fingernail scrapings. 3. Brushing/combing of the person’s hairy region: head, body and pubic. 4. Samples of the person’s hair: head, body and pubic.

Fig. 26.18: Victim of rape: Genital injuries with blood stains on the thigh (Courtesy: Dr KWD Ravi Chandar, Prof and HOD, Forensic Medicine, MMC, Mysore)

5. Urethral, perianal, vulval swabs, vaginal content aspiration and swab, and cervical swab to be collected under direct visualisation. Ideally it should be collected prior to the examination to avoid contamination. 6. Sample of blood. Laboratory Investigation: In majority of sexual assault cases, the physical evidence generally encountered is: Blood, Semen and Saliva. There is an array of analytical tests for these physical evidences; however, it is beyond the scope of this book to consider each and every test. Several tests for detection of semen are mentioned below for the benefit of the readers, as even with limited resources, some of the tests can be conveniently performed. DETECTION OF SEMEN The type of physical evidence most frequently associated with sexual assault cases is semen. The very presence of semen is indicative of the occurrence of sexual activity.1-6, 26 Process of Collecting Biological Samples a. Dried Stains: Application of absorbent swabs moistened in distilled water or normal saline. b. Wet Stains: Under direct visualisation any liquid secretions in the body cavities can be collected by aspiration or insertion of dry absorbent swabs.

Fig. 26.19: Victim of rape: Rape and murder. Forceful sexual intercourse results in ecchymosis in parts of genital organ, and tearing of hymen at 5, 6 and 7 o’clock position

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Part IV: Clinical Forensic Medicine Fig. 26.20: Victim of rape and murder: Nudeness, presence of vegitation and soil, bleeding perineum are diagnostic of rape

Fig. 26.21: Virgin victim of rape (same as in Fig. 26.20): swelling, gaping of vulva and perineal tears corroborates sexual assault

Fig. 26.22: Vaginal smear showing spermatozoa (Courtesy: Dr Udaypal Singh, KMC, Warrangal, Andhra Pradesh)

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Screening Tests For identification of occult seminal stains, to confirm the sampling location, and as presumptive test for semen. 1. Ultraviolet Light Scanning: Helps in identifying occult semen stains. Dried seminal stains fluoresce under UV illumination. 2. Chemical Tests: • Barberios’ test: Detects the presence of spermine, one of the constituents of semen. One drop of the stain extract

is placed on a glass slide under a cover slip. Then it is charged with a drop of saturated aqueous solution of picric acid (1 g picric acid in 30 ml of distilled water) and allowed to diffuse uniformly. Examine under 100× objective of a microscope for needle shaped yellowish spermine picrate crystals indicating presence of semen. • Fluorescent test: Detects the presence of choline, one of the constituents of semen. One drop of stain extract is placed on a glass slide under a cover slip. Then it is charged with a drop of Fluorescent reagent (1.65 gm potassium iodide, 2.54 gm of iodine and 30 ml of distilled water) and allowed to diffuse evenly. Examine under 100 × objective of a microscope for brown rhombic or needle shaped crystals of choline per-iodide, indicative of semen. • Seminal Acid Phosphatase (SAP) It is an enzyme present in varying amounts in different body fluids. Seminal fluid has a high concentration of SAP- 400-8000 King Armstrong (KA) units and its activity in human semen is 500-1000 times greater than in any other human body fluid. The enzyme has the property to cleave a variety of organic phosphates, based on which several tests are available, e.g. Brentamine test, P-nitrophenyl phosphate, alpha-naphthyl phosphate, thymolphthalein monophosphate, etc. These tests are sensitive but not specific for semen owing to the presence of the enzyme in other tissues including vaginal fluid. Besides, there is considerable variation depending on a number of factors- pregnancy, phase of menstrual cycle, bacterial vaginosis, etc. Presence of more than 25 kA units per ml of extract from 1 sq cm of the stained area is considered to be positive reaction and consistent with the presence of semen. • Other markers like creatinine phosphokinase, lactate dehydrogenase isoenzymes, etc. have also been employed for detection of presence of semen in the stain extract. Confirmatory Tests The seminal stain is processed for extraction, which yields a supernatant and a cell pellet. The cell pellet is used for detection of spermatozoa and for DNA analysis while the supernatant portion is used for detection of noncellular markers in semen and to develop genetic profiling or grouping. 1. Microscopic Examination: Depending on the time elapsed since the crime, spermatozoa may be alive and motile or dead. Identification of one or more spermatozoa is conclusive proof of the presence of semen and affirms sexual contact. • Motile sperm: It is best accomplished when the examination is done at the time of collection of the evidence. The technique requires preparation of a wet mount slide (vaginal or cervical swab sample) placed on a slide with a drop of saline covered by a cover slip and examined under a phase-contrast microscope. • Nonmotile sper m: Can be detected from the examination of stained smear preparation. Smear is prepared at the time of collection of the evidence from the swabs or from the cell pellet of the stain extract. Commonly employed staining methods include Gram’s, Hematoxylin and Eosin, Papanicolaou (PAP smear) and Oppitz (Christmas-tree-stain) stains. To prevent artefact from the selective degradation of cellular debris, the cell

Individualisation of Semen Evidence: On confirmation of the presence of semen in the extract, further tests are subjected to individualise the semen. It is achieved by typing the questioned biological stains in various genetic markers system and compared to reference samples obtained from individuals who may be possible donors of the stain. Based on the results obtained, an individual is either included or excluded as being the stain donor. Genetic markers are inherited biochemical substances that exhibit variation (polymorphism) in the population. BLOOD GROUP TYPING ABO group typing can be done only among secretors. Secretors are those individuals who secret soluble ABO agglutinogens in their body fluids. They comprise about 80 per cent of the population. Seminal ABO group typing can be done by several methods: absorption-elution, absorption-inhibition or mixed agglutination. Blood group isoagglutinins can be determined by Lattes Crust method. As with other marker assays, temporal, qualitative, methodological and physiologic variables may limit the usefulness of the blood group contribution to the genetic profiling. The advantage of traditional grouping is—the procedures are cheap, universally available and it may be the only option in case where the stain contains few or no cells. Enzyme Typing Enzyme markers commonly used in genetic profiling of semen are phosphoglutamase (PGM) and peptidase (Pep A). These enzymes are found in semen and vaginal secretions regardless of ABO type or secretor status. PGM is polymorphic in all populations and can be subdivided into 10 distinct subgroups. Pep A is polymorphic in many racial groups and is commonly employed as a discriminator in cases where the perpetrator is suspected to be black. DNA Profiling The primary advantage of DNA profiling in sexual assault investigation is its ability to accurately individualise semen that contains only minimal number of spermatozoa. Besides it can also differentiate multiple donors in mixed stains. POSTCOITAL INTERVAL (PCI) It is the time lapsed since last act of sexual intercourse (time interval between the deposition and collection). 28 PCI is determined from the persistence of the seminal materials— spermatozoa, P30, SAP, PGM and Pep A depending upon their

deferential stability. Thus, a significant level of P30 tends to be lost within 24 hr of deposition in the vaginal vault (as measured by immunodiffusion or crossed-over electrophorosis), SAP is normally lost 48 hours postcoitus, PGM drops below threshold by 6 hours, Pep A is not usually recovered after 3 hours and spermatozoa do not normally persist after 72 hours. In deceased individuals these seminal compounds can last for several days, depending upon the environmental condition and the rate of decomposition. SIGNIFICANCE OF MEDICAL EXAMINATION OF SEXUAL ASSAULT Medical evidence of rape can be derived from: • Presence of stains of body fluid and foreign materials in the clothing and body including genitalia of the victim or vice versa. • Presence of marks of struggle or violence in the body and clothing inflicted by the accused or vice versa. • Evidence of injuries in and around genitalia of the victim. • Presence of semen in the vagina of the victim. • Evidence of implanted venereal disease on the body of the victim. However, in the legal context, to constitute the offence of rape there need not be full penetration of the vagina by the penis with emission of semen and rupture of hymen. Even the slightest penetration or even touching the vulva without producing any injury to the genitals including hymen or leaving any evidence of seminal emission will be sufficient to constitute the offence. Thus the medical proof of sexual intercourse is not the legal proof of rape. The multitude of individual variations and complexity of mechanism that comes into play at the time of commission of the crime may weaken the medical evidence, yet it is not excluded in the court of law. In many instances such as, the proof of seminal emission in a victim who is below 16 years of age or injuries in the genitals provides the proof of rape. Besides, establishing that sexual contact has in fact occurred, the role of medical evidence in sexual assault crimes not only helps to associate the victim and suspect with one another, but also to corroborate or dispute accusations by the parties involved.

Chapter 26: Sexual Jurisprudence

extract can be treated with a mixture of proteinase K and sodium dodecyl sulphate before staining and microscopic examination. The slides are preferably examined under 400X light microscope. 2. Noncellular semen markers: To detect the presence of specific and unique seminal plasma markers. • P30 (Prostate Specific Antigen/PSA): It is a glycoprotein derived from the prostate epithelial cells and is found in seminal fluid, male urine and blood, but not found in any female tissue or body fluids. Also there is no significant difference of P30 level between vasectomised and nonvasectomised individuals.27 • Monoclonal Antibody Mouse Antihuman Semen5 (MHS-5): It is secreted by the seminal vesicle epithelium and is not found in any other body fluid besides semen and has no cross reactivity with other body fluids.

Examination of the Accused When the accused of a rape case is produced for medicolegal examination, it is conducted under section 53 and 54 CrPC.29 Except some differences, the procedure is almost the same as with examination of rape victim (remember the 3G’s) and report (see Proformas 26.1 to 26.3): • General procedures (Prelimiaries)—refer above • General examination–refer above (Figs 26.24 to 26.26) • Genital/local examination. Genital Examination (Fig. 26.25A): Elicit the following: 1. Development of genitalia 2. Injuries suggestive of forcible sexual intercourse such as: • Bruises, nail scratch marks, etc. by the victim in resisting the act of rape • Tearing of prepuce, frenulum, etc. due to forcible penetration. 3. Swabs from the urethra, shaft and glans are collected in addition to the above-mentioned physical evidence. 4. Lugol’s iodine test Principle: During sexual intercourse, vaginal epithelial cells, which are transferred to glans penis are confirmed by this test.

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Part IV: Clinical Forensic Medicine Fig. 26.23: Vaginal epithetial cells stained brownish with Lugol’s iodine (Courtesy: Dr Udaypal Singh, KMC, Warrangal, Andhra Pradesh)

Procedure: It is a simple test, wherein the glans penis is mopped with a filter paper and the paper is then exposed to Lugol’s iodine vapor. A brownish discoloration on the paper is suggestive of presence of vaginal epithelium, which is rich in glycogen content, responsible for color change on the paper (Fig, 26.23) shows vaginal epithelial cells stained brownish by Lugol’s iodine. Absence of smegma: Normally the glans penis when covered with prepuce will allow deposition of smegma in it. During sexual intercourse smegma gets washed off in vaginal secretions. Hence, testing the washings of glans for absence of smegma corroborates rape (smegma can be washed off at bath). If smegma is present it rules out sexual act, within 24 hours) (Fig. 26.25B).

Fig. 26.24: Examination of the accused (male) of rape— general/physical examination

Feigned Rape Condition wherein a woman pretends to have been raped is known as feigned rape. The concept of rape is deceptively simple, and women who make false allegations often structure their complains in such a way that they seem to meet the requirements of rape but ignore its reality. Investigating Suspected False Rape Allegation: 1. Motive for this being several are enumerated as: • When her illicit sexual activities are exposed. • When she becomes pregnant out of illicit sexual relationship • Taking revenge on a boy. 2. History not consistent. 3. Crime scene does not support story. 4. Damage to clothing is inconsistent with any injuries. 5. Injuries not consistent with history, defense wounds, do not involve sensitive tissues. 6. Injuries are of self-inflicted type. 7. Fingernail scrapings of the victim reveal her own skin tissue. 8. Confirmatory laboratory findings are negative. 9. Dubious personality and lifestyle. Medicolegal Questions on Rape • Rape and resistance (refer above) • Raping a woman in deep sleep—it is impossible to rape a woman in sleep, as usually sexual intimacy can wake up the woman. • Anaesthesia and rape charges—often after anesthesia, a woman may feel that she has been raped. Hence, it is better to give anesthesia in the presence of a nurse. 370

Fig. 26.25A: Examination of the accused (male) of rape—genital examination

Fig. 26.25B: Smegma on the glans penis (Arrow)

Chapter 26: Sexual Jurisprudence

• Rape by false impersonation (fraud)—cases of sexual intercourse by false impersonations are often reported, especially if the woman had never or only once seen her husband. • Rape by misrepresented facts—especially with young innocent girls, this is quite often a possibility. Case Example An innocent young girl with suppressed menses was convinced by doctor that the act he is going to perform would cure the problem, performed sexual intercourse with her, which not only amounts to rape but also infamous conduct (adultery) and punishable.

• Death during sexual intercourse – though this is rare, it is not impossible. • Death following rape (refer above). Standard proforma of examination of a rape case is provided in Proformas 26.1 to 26.3. INCEST Incest means an offence wherein sexual intercourse is practiced between a man and a woman who are within restricted relationship in a family (blood relation) and society such as father and his daughter, mother and her son or brother and his sister, etc. Medicolegal Importance It is prohibited and consent given by woman here is not a defense. This is not punishable in India, unless it amounts to rape.20,29 However, such cases may occur more in number than what is reported.1 UNNATURAL SEXUAL OFFENCES Definition IPC Section 377 defines unnatural sexual offences as voluntary sexual intercourse against the order of nature with any woman, man or animal.20 Punishment given Imprisonment for 10 years and fine. Classification All unnatural sexual offences are classified as sodomy, buccal coitus, lesbianism and bestiality. Types of unnatural sexual offences are depicted in Table 26.5. SODOMY (Anal Intercourse, Greek Love, Buggary) Definition Sodomy is defined as anal intercourse performed by a male with another male/female who may be a child/adult, with or without consent and by force. Historical aspect In the old Biblical town called Sodom in ancient Rome, this type of sex was more common in practice even among married couples, to avoid unwanted pregnancy and thus the term sodomy emerged. It was introduced and became a common practice in India during the Moghul period.30 Terminologies: Following four terminologies are important in connection with sodomy, 1-6 • Active agent—is a sodomist male who performs the anal intercourse actively. • Passive agent—is a sodomist male or female who offers the anus, and plays a passive role. • Pederasty—is an adult performing sodomy act involving a male or a female child as his passive agent. • Catamite—is a child who plays a passive role in sodomy. • Gerontophilia—an old male or female who acts as passive agent.

Fig. 26.26: Examination of the accused (male) of rape—specimens (trace evidence)

Incidence: It is common in men who are homosexuals (true invests), sailors, prisoners, military barracks, men’s hostels, etc. These men often act alternatively as active and passive agents mutually. Examination of a Case of Sodomy Examination of a case of sodomy includes three steps (remember 3 Gs): • General procedures/preliminaries • General examination • Local examination. General procedure comprises of the following. • Informed consent for examination—must be obtained prior to examination. • Details on the event—elicit the history of the case from the victim and record in the same version as told. • Penetration—ask if the victim felt the penetration into the anus. • Use of lubricant—ask the victim whether any lubricant was used. General examination comprises of the following: • Examination of clothing (refer examination of rape victim). • Physical examination (refer examination of rape victim). Local examination comprises of the following. • Examination of passive agent • Examination of active agent.

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Examination of Passive Agent It can be dealt under two heads. • Precautions • Clinical findings. Precautions • Ask the patient to undress • Keep a male/female nurse during examination • Put the patient in “knee-elbow” position (Fig. 26.27A) • Use an anal speculum for examination. Clinical findings: These may vary depending on type of passive agent, who may be a habitual passive agent or forcibly victimised (non-habitual) passive agent. 1. Findings in habitual passive agent (Fig. 26.27B) will be as follows. — Shaving of the anal and perianal hairs — Loss of normal puckering around anus — A funnel-shaped depression between buttocks around anus — Skin around anus thickened and smooth-due to frequent friction — On per rectal (PR) examination • Loss of muscle tone (no radial constriction of anus on pinching the skin around anus) presenting a patulous anus • Presence of scars of old tears or fissures • Presence of lubricant/semen/ venereal discharges. 2. Findings in forcibly victimised (non-habitual) passive agent (Figs 26.27C and 26.28). These will be as follows: • Anus may appear to be swollen with temporary loss of tonicity of the anal sphincter • Contusion/laceration of the posterior and mucocutaneous tissue • Seminal or semen mixed with faecal matter or bloodstains may be seen. • If the victim is child, penetration is usually forceful, resulting in tears, and at times prolapse of portion of anal canal, seen. • On per-rectal (P/R) examination—if one finger enters no intercourse may be opined, but if two fingers can be inserted eliciting pain, it is suggestive of anal intercourse. Examination of Active Agent Look for following findings: • Peculiar smell of anal gland secretions • Traces of faecal matter and lubricant used are often detected on the coronal sulcus, frenulum, prepuce, etc. • Abrasions, bruises, lacerations of prepuce, frenulum, glans penis, etc. • Presence of STD lesion/discharge. Note: The shape of the glans penis may be found to be tapering, elongated and constricted, in a habitual sodomist (active agent). All above findings are considered corroborative evidence of sodomy. Medicolegal Importance • In India, sodomy is punishable • In certain western countries it is not so, which has even led to male marriage (gay wedding) • AIDS is suspected to have commenced as a consequence of practice of sodomy.

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Fig. 26.27A: Knee-elbow (Dorsal lithotomy) position

Fig. 26.27B: Findings of sodomy in a habitual passive agent (kneeelbow position). Note: loss of anal puckering, shaving of the area and, marked funnel-shaped depression and smoothening of skin around the anus (Arrow)

Fig. 26.27C: Details of evidence of sodomy on examination

Fig. 26.28: Anal dilatation with anal and perianal injuries is strongly suggestive of sodomy in this child victim

Diagnostic Findings • Faint teeth marks or abrasion on the penis, • Seminal stains on victim’s face, mouth, etc. • Struggle evidence on both when done forcibly. Medicolegal Importance • Punishable if done by force • Punishable if done in public with a consenting partner • Death of a victim especially a child, due to accidental respiratory tract obstruction by the ejaculating bouts of semen leading to mechanical asphyxia.

Chapter 26: Sexual Jurisprudence

Examination of a Case All steps of examination are as for a rape case.

BESTIALITY Definition: Bestiality is defined as sexual gratification by having sexual intercourse with animals. Incidence: Common among “shephard boys” and nymphomaniac females. Fig. 26.29: Sex toys: Dildos, vibrators, vaginal tampons, and artificial vagina and artificial phallus (Source: http://commons.wikimedia.org/ wiki/file:Pleasuretoys-glass-dildo.png; Source: http://en.wikipedia.org/ wiki/artificial_vaginal#materials)

LESBIANISM (Female Homosexuality, Lesbian Love, Tribadism) Historical aspect: In ancient Greece, it was commonly practised in Isle of Lesbos, hence the term lesbianism. Definition: Lesbianism is defined as a mode of deriving sexual gratification by two consenting females, by mutual genital manipulations manually with fingers, lips or extragenital mechanical devices—sex toys (Fig. 26.29). Incidence: It is common in women who are homosexuals (true inverts) in ladies hostels or prisons, among nymphomaniacs, over-attached girls, etc. Examination of a Case All steps of examination are same as for examining the case of rape. Findings in favour are: • Bite marks (love bites), nail scratch marks, abrasions, etc. on mutual genitalia, perineum, breasts, etc. • Injury to vaginal canal (especially if dildos are used) • Women may be more masculine.

Causes: Certain causes are: • Sexual excitement when left alone with animals (pet ones) • False belief among Indian villagers that it is a remedy for curing gonorrhea. Common animal victims: Pet domestic animals like sheep, cow, calf, ass (female), bitch, large birds such as ducks, goose, chicken, etc. by a male offender. Male dogs, monkeys, cats, etc. by a female offender. Examination of a Case Examination of both accused and animal is important. Signs in Accused • Penis/vulva will be found to be contaminated with animal discharges or secretions. • Marks of injury due to animal biting, scratching, kicks, etc. • Presence of animal hair on the garments worn. Signs in Animals • Presence of human semen or sperms in animal passages, injuries on animal genitalia and other natural orifices. • Venereal discharges in animal passages Medicolegal Importance • Punishable if guilty by medicolegal examination of accused. SEXUAL DEVIATIONS (Sexual Perversions)

Medicolegal Importance • The act is punishable when practiced in public places. • Suicidal or homicidal tendencies common among lesbianistic girls due to “morbid jealousy” whenever one of the partners gets married. • Failure of marriage and domestic life certainly occurs in those who are married.

Definition Sexual deviations are certain physical acts or behavioral abnormalities performed without hesitation, to achieve sexual gratification without the actual sexual union.

BUCCAL COITUS (Sin of Gomorrah, Coitus Per Oris, Fellatio, Cunnilingus) Definition: Sexual gratification of a male by performing the act of intercourse into the oral cavity of a sex partner with consent or by force (usually a female partner).

Incidence: It is found to be more common among men. However, it is also true that normally every person has a seed of sexual deviant behavior within the self. As most of these deviations are harmless to the victim, it is rarely bothered to be brought into the notice of law and police. There are certain dangerous perversions, which can result in death of both the performer and his victim, creating problems, e.g. sadomasochism.

Incidence: Usually practised with an innocent child victim. It is often practised as a part of “sexual foreplay” also.

Types of Sexual Perversions Table 26.5 enumerates the types of sexual perversions encountered routinely.

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Psychological Aspect A brief account on Freud’s psychosexual stages of development31 can make one understand psychological aspect of how a person turns out to be a sexual pervert. As per this every human being with his physical maturity, undergoes a psychological maturity also concerned with sex. It is proposed that, this psychosexual development (PSD) maturity occurs from infancy to puberty in the form of five phases, which are narrated as a “sexual maturity ladder” and comprise of: • Oral phase • Urethral and anal phase • Phallic phase • Latency phase • Genital phase Figure 26.30 illustrates the concept and each phase is discussed individually. Oral phase: This phase commences from birth of the child and spreads over to first year. In this phase, the infant develops libidinal impulses through oral cavity, i.e. mouth, tongue, lips, etc. through acts such as sucking, licking, kissing, biting, crying, etc. These are the only modes of expression at this age. Urethral and Anal phase: This extends between 1 and 3 years of age. Here, the libidinal impulse is through anal and urethral passages. The child learns the joy of defaecating and micturating along with the other psychosexual maturity already attained. Phallic phase: In this phase (3-5 years), the child develops the actual curiosity in knowing about the opposite sex. Here, the child tries to realize the differences in each sex, e.g. a boy trying to expose his genital organs (exhibitionism) to a girl and then ask her to show her private parts to him, trying to find out how a girl passes urine by squatting by hiding himself (voyeurism) ultimately trying to achieve pleasure by knowing the facts. Latency phase: In this phase (5-12 years), child apparently stops all sexual preoccupation and develops a super ego. Genital phase: This extends from 12 to 14 years. In this phase, the person reaches the ultimate PSD resulting in all matured heterosexual affections and sexual gratifications, pleasure of manual manipulation of genitals (masturbation), etc. which continues to be maintained throughout life. Onset of Sexual Perversion During the PSD there is a possibility that the maturity can get arrested at any one of these five phases, while physical growth continues further. Such a person will hence restrict all his or

her sexual needs at the level at which the phase of PSD has arrested and he/she will try to get the sexual gratification by all the methods his PSD allows, resulting into sexually abnormal person. Thus, for example, a male whose PSD is arrested at oral phase may turn out to be a person enjoying sex by practicing oral sex, while one whose PSD arrests at phallic phase will try to achieve sexual gratification by adopting-masturbatory or voyeuristic or exhibitionistic acts, etc. Eonism/Transvestism Eonism is also known as transvestism, is a sexual perversion wherein sexual gratification is achieved by wearing the dress of the opposite sex. This is more common in males and he would dress like a female, perform masturbation to ejaculate and thus get sexual gratification. However, the trends of modern fashion of wearing pants and shirts like a male by a female cannot be considered as transvestism. Exhibitionism The exhibitionist gets the pleasure by exposing private parts in public or in front of a opposite sex individual, sometimes performing masturbation. This perversion is common among men. Usually he may be suffering from some other mental disorders. When exposure is aimed to attract a particular woman then, often there is an expectation of similar exposure by the woman or it may be a reflection of a hidden desire to observe the private parts of the woman. This act is punishable under sections 290 and 291 of IPC. Fetishism Fetishism is a type of sexual perversion common among males. Here the individual gets sexual excitement and gratification by merely seeing or feeling of female body parts, certain articles belonging to a woman, such as a sari, footwear, stockings, undergarments, hankies, hairpins, etc. At times a fetish may steal these articles and masturbate and ejaculate on them to get sexually gratified. Masochism Masochism is a rarer sexual perversion, wherein sexual gratification is obtained on being tortured by the sex partner. Virtually this is just the opposite of sadism (refer below). Masochistic asphyxial death (sexual asphyxia) is a dangerous perversion to practise, occurs, when the pervert creates a state of hypoxia (low oxygen level in blood) in him to get orgasm, through partial hanging through a special device, which is selfdesigned and self-regulated. After experiencing orgasm the constriction force around the neck is usually released. As this is often practised in privacy, all alone, and that release of constriction around the neck is not possible if there is a fault in the device under his control, death is inevitable. A masochist is considered to be mentally aberrated person and possibly his childhood experience of cruelty and adversity gets reflected in the masochistic self-torturing. Sadism Sadism is a sexual perversion wherein sexual gratification is achieved by inducing pain on the sex partner.

Fig. 26.30: The sexual maturity ladder

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Historical aspect: It has originated from the French author Marquis D’Sade’ who is known for his novel, which became popular

Incidence: It may be found in both sexes, but is more common among male. Methods Adopted: Biting, pinching, injuring or ill-treating the partner in a very cruel way. In extreme cases even a murder may be committed to derive sexual gratification. This is called “lust murder”. Rarely one may get the sexual gratification by tearing out the genitals or other parts of the body and virtually eating them raw. This is called “necrophagia”. Lust Murder This is the consequence of extreme sadist practice by a male. In this type of perversion, sexual arousal begins with torturing of the sex partner and with death of the partner full gratification is obtained. Often the body of the victim is mutilated. In some cases after full arousal in this way, the pervert performs sexual intercourse with the dead body of the victim till ejaculation and gratification occurs. Sadomasochism Commonly know as bondage. It is a combined form of sadism and masochism in the same individual. Often it is observed that a sadistic husband will have a masochistic wife, or vice versa. Medicolegal Importance • This is a dangerous perversion, as the victim may turn out to succumb into lust murder. • The sadist must be hospitalised for his mental problem. • However, in India sadism is a punishable sexual offense whenever reported. Necrophagia This is another rare from of sadistic perversion seen among male, who gets sexual gratification by tearing out the genitals or other parts like breasts, buttocks, etc. of his partner after her death by his teeth and may virtually eat them raw. Necrophilia Necrophilia is a desire of obtaining sexual gratification by performing sexual intercourse with a cadaver of opposite sex. Males often suffer from such desire and such a male is usually psychosexually incompetent. He feels that this is a most suitable way, as there is no rejection and no one else will come to know about his weaknesses. Often he visits a prostitute for fear of social stigma and fear of exposure of his sexual incompetence. This condition is a result of mental aberration accompanied by personality defect. However, no such pervert will commit murder of a female to have the sexual intercourse and achieve gratification. Voyeurism Popularly known as Peeping Tom or Scotophilia. It consists of achieving sexual gratification by secretly watching others getting undressed, taking bath, or performing sexual intercourse, etc. Orgasm is usually preceded by masturbation, e.g. watching blue film, troilism, etc. Blue Film Blue film is a movie taken while a couple is performing sexual union and exhibited to the audience in a theatre or video parlour. Here both the couple performing as well as the audience watching this in the theatre may be considered as sexual perverts, former ones exhibitionists and the latter voyeuristic.

The art of taking photographs of nude men and women and also clicking while couples perform sexual intercourse in different perspective and then publishing them in the form of books constitutes pornography. This is banned in India for reasons not only because it is immoral, but also because it might encourage unhealthy activities such as promiscuous sex, prostitution, sexually transmitted diseases, etc. in the nation. Troilism Troilism is an extreme degree of voyeurism wherein a perverted husband gets sexual gratification by watching his own wife performing, sexual intercourse with another man.

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for his methods of inducing pain and torturing for deriving pleasure and sexual gratification.

Masturbation This type of perversion comprises of an act of deliberate, manual handling or self manipulation of genital organ by fingers or mechanical devices till ejaculation in a male and orgasm in a female, i.e. achieving sexual gratification occurs. Incidence: Masturbation is a common mode of sexual perversion observed both among men and women. Medicolegal Importance: According to newer concepts, this is not considered a perversion, but a harmless sexual activity towards attaining sexual maturity. However, masturbating in public is immoral and punishable. Death may result in cases wherein an electrical device is used for the purpose and is not handled carefully or is in a faulty condition. Nymphomaniac Nymphomaniac is a type of perversion of excessive sexual desire in a woman, wherein the woman is in need of sex frequently, irrespective of whether it is by normal or abnormal sexual acts, such as masturbation, sexual intercourse, oral sex, sodomy, lesbianism, bestiality, etc. Satyriasis Satyriasis is excessive sexual desire, arousal and drive in men. These subjects are liable to commit sexual offenses like rape or practise other abnormal sexual acts such as sodomy, fellatio, bestiality, masturbation, etc. to get gratification and are dangerous to the society. Frotteurism Frotteurism is a mischievous act usually practiced by a male sex-pervert in a crowded place to derive sexual gratification by pressing/rubbing his genital part through the dresses worn, against body parts of a female in front of him. As per sections 290 and 291 IPC, this is a punishable offense in India. Undinism Undinism is a rare type of sexual perversion, common among men wherein the pervert achieves sexual gratification by watching the act of passing urine or defaecating by woman. The perversion may take bad shape when the pervert achieves the sexual gratification not only by watching the act of passing urine by a woman but combined with exhibitionism, masturbation, voyeurism, etc. Indecent Assault Any offense committed on a female with an intent or knowledge to outrage her modesty. This is usually sexually motivated and obviously done without her consent.

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This includes: • Kissing of any part of female body • Touching, pressing the breasts or private parts, including thighs • Exposing a female’s genital parts, breasts, etc. • A medical practitioner can be accused of indecent assault if he examines a female patient by stripping her clothes without her consent. LAWS IN RELATION TO SEXUAL OFFENCES IN INDIA20,21,29 1. Section 375 IPC defines rape. 2. Section 376 IPC describes punishment for rape. 3. Section 377 IPC defines unnatural sexual offenses as well as describes punishment. 4. Section 53 CrPC states that when a person accused of sexual offence referred to a doctor for examination by Police Officer not below the rank of Sub-Inspector, he need not take consent from the accused for examination. If he refuses to get examined, mild degree of force can be used to examine him. 5. Section 54 CrPC provides an opportunity to an accused of a sexual offence to get examined physically to disprove the charges. ABORTION (MISCARRIAGE, FOETICIDE)32-35 Definition Abortion is defined as the premature expulsion of the products of conception prior to completion of the total period of gestation. Products of Conception It is designated by several terms and they are as follows: • Fertilised ovum—from fertilisation till implantation, which usually occurs within 1st to 2nd weeks of conception (Fig. 26.31). • Embryo—denotes the developing product of conception after its implantation in the uterus up to the end of second month, when usually placenta develops (see Fig. 26.31). • Foetus—the product of conception from the 3rd month till birth. Classification Depending on the way of induction, abortion is classified into two groups: 1. Natural abortion 2. Artificial or induced abortion which could be again of two types: • Justifiable or therapeutic abortion (Medical termination of pregnancy–MTP) • Criminal or non-justifiable abortion. Differences between natural and criminal abortions are depicted in Table 26.6.

Fig. 26.31: Products of conception (clots expelled) suggestive of placental structures (chorionic villii) confirmed histopathologically

Natural Abortion (Spontaneous Abortion) Natural abortion is an abortion that occurs spontaneously without any induction procedures and usually coincides with a menstrual flow. Incidence It is more common in the earlier period of gestation (2nd-4th months). Causes Causes of natural abortion could be paternal or maternal or fetal in origin. 1. Paternal—usually due to syphilis, tuberculosis, old age or general debility. 2. Maternal • Uterine causes—cervical incompetence and other pathological conditions of uterus. • Constitutional causes—syphilis, acute fever, diarrhea, diabetes, jaundice, anemia, etc. • Nervous/mental causes—shock, sudden fright, sudden joy or sorrow, etc. • Violence/trauma—fall from height, blows or kicks on the abdomen, etc. • Acute/chronic poisoning with lead, copper, mercury, etc. 3. Foetal • Inflammation and fatty degeneration of the placenta • Faulty development • Syphilis Differential Diagnosis of Blood per Vagina • In a pre-pubertal girl—it could be injury, rape, foreign body, etc.

Table 26.6: Differences between natural and criminal abortions

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Particulars

Natural abortion

Criminal abortion

Predisposing factor Infection Injuries in and around genitals Mucosa of genitalia and uterus

Diseases of uterus, placenta may be present Rare Absent Changes of pregnancy may be present

Foreign bodies

Never found

History of pregnancy due to illicit sex may be present Frequent Often present Ulceration, edema, congestion, etc. in vagina/cervix due to local application of irritant substance may be present May be found

Criteria

Frank blood

Menstrual blood

Source Clotting Odour Microscopy

Arteries/veins + ve – ve RBC, WBC, platelets, etc.

Denuded endometrium – ve + ve (Foul smell) Endometrial glands and vaginal epithelial cells

• In women in the child bearing age (14-45 years) – it could be injury, menstruation (Table 26.7), rape, criminal abortion, lochia, fibroid uterus, dysfunctional uterine bleeding (DUB), etc. • In postmenopausal age– DUB or malignant tumours.

3. Beyond 12 weeks and up to 20 weeks pregnancy, opinion of second practitioner must be obtained to justify performing the abortion. 4. MTP must be done only in well-equipped hospitals authorised by the government.

Medical Termination of Pregnancy/MTP (Justifiable Abortion, Therapeutic Abortion) Medical termination of pregnancy is an abortion induced by a medical man in good faith to save the life of the mother for proper therapeutic need. The following conditions must be fulfilled to perform a justifiable abortion. 1. Written consent of both the woman and her husband or legal guardian. 2. Consultation with another medical man, usually a specialist or one who is superior in qualification and experience. 3. Proper indication of performing the abortion: • Systemic diseases – cardiac failure, severe hypertension, severe toxemia of pregnancy, advanced renal diseases, epilepsy, etc. • Gynecological indications — Carcinoma of the genital organs — Threatened abortion with severe bleeding — Uterine sepsis due to attempted criminal abortion • Conditions causing fetal abnormality- infective conditions like rubella, significant exposure of mother to teratogenic agents, etc.

Methods of Inducing MTP This depends on duration of pregnancy in each case. 1. In first three months of pregnancy following are opted: • Dilatation and curettage (D and C) • Vacuum suction and curettage Under both these methods, the cervical canal is first dilated by no.4-Hegar’s dilator under local or general anaesthesia and then products of conception removed by either scooping out by a uterine curettage or sucked out by connecting to vacuum suction evacuation equipment. 2. In pregnancy beyond three months following are opted: • Induction by prostaglandin E1 and E2, which bring about uterine contractions and expel the fetus. • Amniocentesis – is a minor surgical procedure wherein using an amniocentesis needle, amniotic fluid is withdrawn and replaced with equal volume of 20 per cent saline/50 per cent glucose per abdominally. This results in expulsion of uterine contents with in 48 hours after injection. • Abdominal hysterectomy— is a surgical procedure of removing the fetus, preferred after 4 months of gestation.

Abortion Law in India MTP Act, 1971 and MTP rules, 1975 have liberalised abortion in India. 32 As per this Act, a qualified registered medical practitioner is allowed to undertake termination of pregnancy under following circumstances: Therapeutic indications: Pregnancy would be a risk to the life of the mother or may cause physical or mental illness of the mother. Eugenic indications: There is significant possibility of the child being born with physical and mental abnormalities. Social indications: Failure of family planning methods in married women. Humanitarian indications: Pregnancy caused by rape, pregnancy in lunatics, etc. MTP Act Rules 1975 to Be fulfilled 1. Written informed consent of the woman before performing abortion is mandatory. The woman to be aborted should be above 18 years of age. However, consent can be obtained from the parents or guardian when she is a minor or mentally unsound. 2. Up to 12 weeks pregnancy, any qualified practitioner can perform an abortion. However, he must have undergone compulsory training.

Chapter 26: Sexual Jurisprudence

Table 26.7: Differences between frank blood and menstrual blood

Criminal Abortion Criminal abortion is an unlawful expulsion of the products of conception at any stage of gestation by an unqualified person or a qualified doctor. Motive for Criminal Abortion 1. To get rid of a child following illicit intercourse with a view to avoid the shame and disgrace in case of: • Widows • Unmarried girls • Married women conceiving during long absence of their husbands or living separately from their husbands. 2. To prevent inconvenient addition to the family. 3. The heir presumptive may procure abortion of the female, whose husband’s property he is to inherit in the absence of a child of her own. Methods Adopted in Inducing Criminal Abortion Usually mechanical violence is used by several means (Fig. 26.32) such as: Extrauterine Means • Violent exercise, such as horse riding, cycling, jolting and lifting of heavy weights. • Severe shock as in kicks and blows over the abdomen and falling or jumping from a height. • Blood letting, by application of leeches to the vulva, perineum or inner aspect of thighs

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plumbago, etc. are used for the purpose. One end of this stick, which is wrapped, with a piece of cloth or cotton wool, is soaked in or smeared with an irritant or any abortifacient substance. This is passed into the uterus, per vaginally, resulting in expulsion of product of conception.

Fig. 26.32: Materials used for causing criminal abortion: (1) Hair pin, (2) Syringe, (3,4,5) Abortion stick, (6) Root of abortifacient plant, (7) Douche, (8) Part of Hagginson’s syringe

• Kneading or firmly massaging the anterior abdominal wall • Tight compression of the lower abdomen. • Drugs such as ecbolics, emmenogogues. Uterine Means • Vaginal douching-alternative hot and cold water douching of vagina is proved to result in abortion • Injection of soap water into the vagina can induce abortion • Abortion stick—is a wooden stick measuring 10 to 15 cm in length and 0.5 to 1 cm in diameter. Usually a branch of vegetable irritant plant such as: calotropis, marking nut,

Danger of the stick: It could result in any of the following: – Shock – Haemorrhage – Sepsis – Perforation – Peritonitis – Absorption of poison from vaginal or cervical mucous membranes leading to generalised poisoning – All these complications may terminate fatally, resulting in death of the patient. – Electricity—110 volts of electric current via negative pole applied to posterior vaginal cul-de-sac and positive pole to lumbosacral region can lead to abortion. – Use of abortifacient drugs such as: Drastic purgatives like croton oil, magnesium sulphate, aloes, etc. which are drastic purgatives acting on rectum. Ecbolics like ergot, quinine, posterior pituitary extract, etc. which act by increasing uterine contractions result in abortion. Cause of Death in Criminal Abortion Causes are several (Fig. 26.33) and are classified as immediate, delayed and remote causes. 1. Immediate causes: • Reflex vagal inhibition following instrumental evacuation or from sudden dilatation of vagina and cervical canal by the passage of instrument. • Air embolism from faulty syringing. • Soap embolism from improper introduction and absorption of soap solution. • Shock and haemorrhage from injury to vaginal, uterine or pelvic vessels.

Fig. 26.33: Diagram illustrating complications of criminal abortion

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Signs of Criminal Abortion 1. Profile of victim – usually unmarried girls or widows 2. On examination the patient may show following: • Laceration of the vagina and cervix • Marks of violence on the abdomen of healthy women • Evidence of sepsis – like pelvic cellulitis, peritonitis, etc. • Injuries on the foetus • Evidence of burns over the back may be found in a criminal abortion induced by electrocution • Presence of the parts of the abortion stick or foreign body in the uterus or vagina • Reddening and blistering of vaginal mucosa when irritants are used • Perforation of the uterus, when abortion stick is used. Examination of a Case of Criminal Abortion Includes following steps: • Procedural formalities • Examination of the alleged woman • Examination of the material alleged to have expelled out. Procedural Formalities: These include the following: 1. Requirement before examination: • Requisition from the magistrate • Identification of the female • Written consent of the female • Result of the examination should be appraised before hand. 2. Precautions: It is better to keep a female witness (nurse) or the husband of the woman undergoing MTP. 3. Other particulars: Note the following: • Short history of the case • Date and time of abortion • Physical and mental conditions of the patient • Examination of the clothing • Age of the victim is to be determined. 4. Enquire into facts about the woman aborted, means adopted to procure criminal abortion, and the material expelled out of the uterus.

• Mucous membranes of stomach and intestines are congested if an irritant poison was swallowed to procure abortion • Uterus is enlarged and its cavity contains portions of decidua. Some of the products of conception may be found. Placental site with the gaping placental sinuses may be seen. Ovaries are congested and on section, show the presence of corpus luteum. Uterus may show injuries of different degrees (Figs 26.35 to 26.37). Examination of Material Alleged to have been Expelled out • This may be blood clot, shreds of membrane, a hydatidiform mole, fibroid tumor, polyp, an embryo or an immature foetus. • Traces of ovum are searched for in the material after washing it in a basin of water. Abortion cannot be definitely established, unless the products of conception are found. • If it is a foetus, its intrauterine age is determined. The viability of the child is also noted (210 days – viable age). • Note the length, weight, and stage of development of the baby and whether it is stillborn or live born. Blood group test may determine its maternity. Whether abortion is done or not, even its attempt on a woman is illegal. The abortion attempted on a woman, who is later proved to be not pregnant is illegal too [abortion- if attempted or carried out on therapeutic or medical grounds in the interest of the mother, is however not considered to be illegal]. • After the death of a pregnant woman, if body is highly decomposed, the contents will come out spontaneously due

Chapter 26: Sexual Jurisprudence

2. Delayed causes (2-3 days): • Septicemia following infection. • Pyemia from pelvic abscess. • Generalised peritonitis following perforation of uterus or of the bowel by the instrument. • Tetanus. 3. Remote causes (beyond 3 days): • Renal failure. • Pulmonary embolism from dislodged thrombus. • Systemic poisoning by absorption of abortifacient drugs. • Secondary infection—pneumonia, empyema, meningitis, etc.

Fig. 26.34: Foreign body (twig of an abortion stick) inside the uterus, noticed at autopsy in a victim of criminal abortion

Examination of the Alleged Woman (Victim) In the living: This should be elicited as early as possible, otherwise many of the important signs will disappear within seven days. The signs of recent abortion, i.e. findings within first 4 to 5 days and other findings are same as those of recent delivery. These are already discussed above under the heading ‘delivery’. In the dead: In addition to above signs we may find following internal postmortem findings: • Foreign body inside the uterus (Fig. 26.34) • Extravasated blood under the bruised portions

Fig. 26.35: Rupture of uterus (right side) and extruded amniotic sac with foetus (left side) as noticed during autopsy, victim of criminal abortion (Courtesy: Dr Zachariah Thomas, Dept. of Forensic Medicine, Medical College, Trivandrum, Kerala)

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5. Poisons or chemicals used for the abortion can be detected from the placental tissue.

Fig. 26.36: Autopsy finding of uterus—atonic flabby with retained clots in postpartum haemorrhage case (Courtesy: Dr Zachariah Thomas, Dept. of Forensic Medicine, Medical College, Trivandrum, Kerala)

Relevant Sections in Laws on Abortion in India20,21 • Section 312, Indian Penal Code (IPC) states that abortion induced not for the purpose of saving life/good of the woman, be punished with imprisonment for 3 years. If the woman is “quick with child” the period is extended for 7 years more. • Section 313 IPC, states that if abortion is done without the consent of the woman, punishment is life imprisonment • Section 314 IPC, states that if the woman dies after an abortion, which is done with her consent, punishment is life imprisonment. • Section 315 IPC, states that preventing a child born alive or causing it to die after birth, is also punishable. • Section 317 IPC, exposure or abandoning infant are both punishable. • Section 318 IPC – concealment of birth and secret disposal of foetus are also punishable. REFERENCES

Fig. 26.37: Ruptured ectopic pregnancy with decidual cast inside the uterine cavity (Courtesy: Dr Zachariah Thomas, Dept. of Forensic Medicine, Medical College, Trivandrum, Kerala)

to the pressure of gases of putrefaction (postmortem delivery). Even the uterus may prolapse. Medicolegal Aspects In a case of an attempt to cause abortion or miscarriage, it is not necessary to prove that the woman was pregnant. But in awarding punishment, the following points are usually considered by the court: • Whether the woman was pregnant or not (proof of pregnancy) is required for actual abortion, but not for attempt to do it. • Whether the woman was quick with the child. The offence is grave when the woman was quick with child. • Whether the abortion or its attempt has been done with or without the consent of the woman. In either case, punishment is by life imprisonment. • Whether death of the child was caused by the act. • Whether death of the woman was due to the abortion or its attempt.

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Medicolegal Importance of Placenta 1. It gives the duration of pregnancy. 2. Abnormality or disease condition of placenta can result in spontaneous abortion. 3. Injured placenta may point to criminal abortion. 4. Pieces of placental tissue retained in the uterus will confirm the diagnosis of abortion.

1. Rao NG. Clinical Forensic Medicine (5th edn). HR Publication Aid: Manipal, 2003. 2. Mathiharan K, Patnaik AK. Modi’s Medical Jurisprudence and Toxicology, 23rd edn, Lexis Nexis Butterworth’s, 2005. 3. Dogra TD, Lt. Col. Rudra Abhijith (Eds). Loyn’s Medical Jurisprudence and Toxicology, 11th edn. Delhi Law House, New Delhi, 2005. 4. Mukharjee JB. Forensic Medicine and Toxicology-Vol I, 2nd edn. Arnolds: Associates, Calcutta, 2000. 5. Nandy A. Principle of Forensic Medicine (1st edn). New Central Book Agency: Calcutta, 2000. 6. Parikh CK. Parikh’s Medical Jurisprudence and Toxicology for Classrooms and Courtrooms (6th edn). CBS Publishers and Distributors, New Delhi. Reprint 2002. 7. Internet Source: Incidence of erectile dysfunction, Retrieved on: May 24, 2009; http://www.urologychannel.com/ errectiledysfunction/index.shtml 8. Internet Source: Causes and treatment for frigidity, Retrieved on: May 24, 2009; http://www.hubpages.com/hub/CausesandTreatments-Frigidity 9. Internet Source: What causes Vaginismus? Retrieved on May 24, 2009: http://www.vaginismus.com 10. Min JK. Guidelines for the number of embryos to transfer following in vitro fertilisation. J Obstet Gynaecol Can. Sept 2006;28(9):799813. 11. The Practice Committee of the Society for Assisted Reproductive Technology and the Practice Committee of the American Society for Reproductive Medicine. Guidelines on number of embryos transferred. Fertil Steril. Nov 2006; 86 Suppl 5:S51-2. 12. Jackson RA, Gibson KA, Wu YW, et al. Perinatal Outcomes in Singletons following in vitro fertilisation: a meta-analysis. Obstet Gynaecol 2004;103:551-63. 13. Internet Source: 20th Century History: First Test Tube Baby: Louise Brown: http://eebweb.arizona.edu/courses/ecol223/First%20TestTube%20Baby%20-%20Louise%20Brown.pdf. 14. Schwartz LL. Surrogate motherhood I: responses to infertility. [Journal Article]; Am J Fam Ther 1987; 15(2):158-62. 15. Schwartz LL. Surrogate motherhood II: reflections after “Baby M. [Journal Article]; Am J Fam Ther 1988;16(2): 158-66. 16. Janssens, P.M.W. 1, EDITORIAL COMMENTARY, Colouring the different phases in gamete and embryo donation, Human Reproduction. March 2009;24(3):502-4. 17. González Casbas JM, Calderay Domínguez M. Requests for utilisation of a semen bank among oncological patients. Semen cryopreservation prior to chemotherapy, radiotherapy and surgery; Arch Esp Urol. 2004 Nov; 57(9):1017-20.

27. Bill O. Gartside, Kevin J. Brewer, Carmella L. Strong, Estimation of Prostate-Specific Antigen (PSA) Extraction Efficiency from Forensic Samples Using the Seratecâ PSA Semiquant Semiquantitative Membrane Test, Forensic Science Communications 2003;5:2. 28. Memchoubi Ph, Supriya K, Shaini L, Sangeeta N, Gyaneshwar W, Singh Th. Bijoy1; Study of Acid Phosphatase Activity in Post Coital Subjects; Journal of Indian Academy of Forensic Medicine 2007;29:1. 29. Chandrachud YV, Manohar VR, Avtar Singh, The Code of Criminal Procedure (Act II of 1974), 17th edn, (Thoroughly Revised and Revitalised), Wadhwa & Co. Nagpur, New Delhi, 2004. 30. Internet Source: Wikipedia free encyclopedia: Retrieved on May 25, 2009: http://en.wikipedia.org/wiki/Sodomy 31. Internet Source: David B. Stevenson, Freud’s Psychosexual Stages of Development, Retrieved: May 25, 2009: http:// www.victorianweb.org/science/freud/develop.html 32. Internet Source: Medical Termination of Pregnancy (MTP) Act and Rules, Retrieved on May 25, 2009, http://mohfw.nic.in/ MTP.htm 33. Brown DAL, Criminal Abortion-facts or fiction. Am J Forensic Med Pathol 1980;1:219-22. 34. Cinbura G. Studies of Criminal Abortion: Cases in Ontario. J. Forensic Sci. 1967;12:223-9. 35. Teare D. Death in Criminal Abortion. Med Legal J 1958; 26:1324.

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18. Internet Source: Health Gateway India: Permanent Contraception: Retrieved on 4th May 2009: http://www.indg.in/health/ womenhealth/contraception. 19. Internet source: Wikipedia, the free encyclopedia: Atavism: Retrieved on 24th May 2009: http://en.wikipedia.org/wiki/Atavism. 20. Chandrachud YV, Manohar VR, Avtar Singh, Ratanlal, Dhirajlal. The Indian Penal Code (Act XLV of 1860), 30th Edn, (Thoroughly Revised and Revitalised), Wadhwa & Co. Nagpur, New Delhi, 2004. 21. SK Sarvaria. Ra Nelson Indian Penal Code, 10th Edition, Lexus Nexis, 2008. 22. Rao NG. Practical Forensic Medicine (3rd edn). Jaypee Brothers Medical Publishers, New Delhi, 2007. 23. Robertson REI, Sexual offences: In McClay W (Ed): Rape: The New Police Surgeon, Association of Police Surgeons of Great Britain: Northampton 1984;65-81. 24. Reade DJ. Early investigation of sexual assault. Police Surgeon, 1985;424. 25. Kathleen D. Johnson, MD, Rape and Sexual Assault Pictures and Photographs, 2008;2530(8):4391-455, January 22, 2008, Library of The National Medical society; Retrieved on May 24, 2009, S o u r c e : h t t p : / / w w w. m e d i c a l - l i b r a r y. o r g / j o u r n a l s 5 a / rape_pictures.htm 26. Jean-Pascal Allery, Norbert Telmona, Anthony Blanca, Roger Mieussetb, Daniel Rougéa, Rapid detection of sperm: comparison of two methods, Journal of Clinical Forensic Medicine 2003;10(1):5-7.

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27

Infanticide, Foeticide and Child Abuse

INTRODUCTION The tender age in life such as intrauterine foetal life, infancy and childhood are often exposed to various unfavourable circumstances comprising of diseases and trauma. Broadly they are categorised in to three types: (i) foetal death means death of a foetus at any time prior to birth, (ii) infant/newborn/neonatal death meaning death of a child under one year age due to natural and unnatural causes, and (iii) child abuse: means maltreatment of a child for sexual and nonsexual purposes. The word infanticide is derived from Latin word infanticidium, meaning killing of a child/infant (meaning newborn, baby, toddler, tot, etc).1 Infanticide has been practiced in every continent of the world by people of all cultural complexity, from hunters and gatherers to high civilisation, including our own ancestors. Rather than being an exception, then, it has been the rule. There is ample historical evidence to document the incredible propensity of parents to murder their own children under an assortment of stressful situations. In nineteenth century England, for example, infanticide was rampant throughout the country.2 Two reasons for infanticide stand prominent in history. They are poverty and population control. Darwin believed that infanticide, "especially of female infants," was the most important restraint on the proliferation of early man. While female infanticide has at times been necessary for survival of the community-at-large, there have also been instances where it has been related to the general societal prejudice against females which characterizes most the male-dominated cultures. The data on female death is truly amasing. Estimates indicate that 30.5 million females are "missing" in China, 22.8 million in India, 3.1 million in Pakistan, 1.6 million in Bangladesh, 1.7 million in West Asia, 600,000 in Egypt, and 200,000 in Nepal.2 It is clear that the onerous costs involved with the raising of a girl, end eventually providing her an appropriate marriage, dowry, was the single most important factor in allowing social acceptance of the murder at birth in India. Females are considered as only consumers and that a serious financial burden to poor families. They were therefore often killed at birth. Incidence "In 1966, the United States had 10,920 murders, and one out of every twenty-two was a child killed by the parent".2 Today, infanticide is still most commonly seen in areas of severe poverty. Killing of an infant was described as a crime that was committed by the mother giving birth to that child in medieval times; such likelihood remains true even today. Although men are more likely to murder in general, statistical review of prosecutions show that 382

killing of infant is usually committed by the mother. When mothers killed their children, however, the victim was usually a newborn baby or younger infant within the age of one year.2 Some research shows that for murders of children over the age of one year in the United States, white fathers were the perpetrators 10 per cent more often than white mothers, and black fathers 50 per cent more than black mothers.1,2 Killing of female infant occurs mostly among the poor, in rural population. In India, the main factors that is responsible for the increase in the incidence of killing female infant or foetus is believed to be factor of low status of women, son preference, and the practice of dowry across all casts groups.2,3 Other risk factors can include young maternal age, low level of education and employment, and signs of psychopathology, such as alcoholism, drug abuse or other criminal behavior. The most common method of killing children over the ages has been head trauma, strangulation and drowning. Most of the murders today are committed with the use of the mother's hands, either by strangulation or physical punishment. INFANTICIDE Definition Infanticide is defined as the deliberate, unlawful, destruction of a child under the age of one year, by act of omission or act of commission. However, in India, from the legal point of view, irrespective of the age of the child, the offences against children are dealt with in the same lines as adult. Thus, in our law there is no distinction between infanticide and child murder. Thus, infanticide is considered as killing of a child below the age of one year, and legally it is amounting to homicide. Investigation in a Case of Death of a Newborn and Infant Examine the case by meticulous autopsy and establish answer for the following questions: • Whether the child is viable or not? • Whether the child—live born or stillborn or dead born? • Time of survival if live born. • Cause and manner of death. Whether the Child is Viable or Not? Viable child is a foetus, which has completed of 210 days (7 months) of intrauterine life (IUL) and capable of leading a separate existence after birth. Further questions like live birth, duration of survival and cause of death etc. arise only if it is above the age of viability.

Establishing the viability: Examination of the infant by proper autopsy techniques is the accurate method to establish the viability and following two methods are adopted. • By considering the foetal developmental changes suggestive of attaining the viability • By Haase's formula. Foetal developmental changes: Foetus must be examined for the developmental changes suggestive of viability, as depicted in Table 27.1 and Figures 27.1A to G. Haase's rule/formula: If the crown-heel length (vertex to heel length) of a foetus is known, its intrauterine age (IUA) can be determined as: Principles • Up to 5 months, age of the foetus = Square root of length of foetus (in months) • > 5 months = length of the foetus (in cm)/5 = (months) (Tables 27.2A and B). Thus: • Up to 25 cm of crown-heel length of the fetus, intrauterine age (IUA) in months is calculated by taking square root of the length. Thus, if crown-heel length is 9 cm, the IUA is determined as: IU Age = √9 = 3 months. • Beyond 25 cm of crown-heel length, intrauterine age (IUA) of the foetus is calculated by determining one-fifth of the Crown-heel Length, i.e. dividing the Crown-Heel Length by

5, gives IU Age in months. Thus, if the crown-heel length is 40 cm IU Age = 40 × 1/5, i.e. 40 ÷ 5 = 8 months Measuring Crown-heel Length It is done by measuring the actual length of the foetus placed stretched on a flat surface from top of the head to the heel, utilising a metallic scale actual/flexible measuring tape. It can also be measured using osteometric board, used for measuring the lone bones in osteometry. LIVE BORN, STILLBORN AND DEAD BORN CHILD4-7 Live Born Child A child is considered live born, if any of its part is out of mother's reproductive passage, though it has not breathed or completely born (Figs 27.2A and B). Stillborn Child A stillborn is one who is born after 28 weeks (IU age) of pregnancy, and it did not show any signs of life, at any time Table 27.2A: Changes in foetal length and weight at birth and after birth5-15 S. No.

Parameters

Observations

1.

Length at birth

2.

Length at the end of 6 months Length at the end of 1 year Length at the end of 4 years Weight at birth

Range: 45-34 cm and Median: 50 cm5-9 60 cm

3. 4. 5. 6.

Table 27.1: Foetal autopsy: External and internal developmental changes of viability

I. External

II. Internal

Features

Observations

Length at 7 months IUL Weight at 7 months IUL Eyes: Eye brows/lashes Eyelids Pupillary membrane Limbs Hands and feet Fingers and toes Nail growth Umbilical cord Placental weight Sex Hairs a. Body b. Scalp Skin—vernix caseosa Ossification centres talus 2nd piece of sternum Brain convolutions Intestines Gallbladder bile Meconium in colon Caecum Testis

35-45 cm 1060 gm Formed Open Absent Present Present Present Present Present 350-400 gm Formed Lanugo +ve +ve Present Appeared Appeared Formed Present Present Present In right iliac fossa Between kidney and inguinal canal

Chapter 27: Infanticide, Foeticide and Child Abuse

Medicolegal Importance If on autopsy, the child or newborn is found to be not viable then the charge of infanticide stands withdrawn. Thus, every doctor examining a case of infanticide must establish whether the child or fetus examined is viable or not.

7.

Weight at the end of 5 months Weight at the end of 12 months

68 cm 100 cm (double of length at birth) Range: 2500–4000 gm and Median: 3400 gm10-14 6800 gm (doubles birth weight) 10200 gm (triples birth weight)

Table 27.2B: A rough method of calculating the age of the foetus Haase's rule: • Up to 5 months, age of the foetus = Square root of length of foetus (in months) • > 5 months = length of the foetus (in cm)/5 = (months) For confirmation of age between 6 and 12 years: • Best is dental examination. For confirmation Fusion of bones: • 14 years • 14-25 years • 15-16 years • 16-17 years • 17-18 years • 18-19 years • 18-20 years • 21 years • 22 years

of age between 14 and 25 years: : : : : : :

Patella completely ossifies Sternum fusion takes place below upwards Elbow joint Ankle joint Hip joint Knee, shoulder, inner end of clavicle centres appear. : Iliac crest fuses. : Fusion of ischial tuberosity and inner end of clavicle. : Epiphyseal union of sternal end of clavicle

Bertillon's system : For age >21 years.

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Part IV: Clinical Forensic Medicine Figs 27.1A to G: Foetus of different intrauterine age and developments: (A) 8 weeks, (B) 10 weeks, (C) 14 weeks, (D) 20 weeks IUL, (E) Full term, (F) Full term foetus in the cut opened uterus with lanugo hairs, vernix caseosa, and in a universal flexion position, (G) Foetal hand showing fully grown nails at the finger tips, full term. Courtesy: (Figs 27.1F and G) Dr B Santha Kumar, Professor and HOD, Forensic Medicine, Govt. Stanley Medical College, Chennai, Tamil Nadu)

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after being completely born. In this the foetus was alive in uterus but dies in the birth canal after the birth process has initiated.

Establishing Whether Live Born?

Dead Born Child A dead born child is one which had died in uterus before the birth process has started and shows rigor mortis, maceration or mummification at birth.

• Baby's cry (vagitus vaginalis/vaginus, vagitus uteralis/uterinus, i.e. baby's cry inside the vagina or uterus respectively during delivery). • Muscle twitching/movements of limbs, etc.

In civil cases: Following are considered signs of live birth:

Features

Respired

Unrespired

Shape Circumference

Arched/drum shaped More and greater than the abdomen Increases/wider At the level of 6th or 7th rib

Flat Less than abdomen

Intercostal space Diaphragm

Narrow At the level of 4th or 5th rib

Table 27.4: Time since birth by changes in the umbilical cord Changes observed 1. Shrinkage of blood vessel lumen 2. Drying up at cut end 3. Inflammatory line at the base of the stump 4. Obliteration and mummification changes in artery 5. Obliteration in veins 6. Detach-fall off 7. Complete healing of the umbilicus

Time since birth Just born 24 hr (1 day) 48 hr (2 days) 72 hr (3 days)

Chapter 27: Infanticide, Foeticide and Child Abuse

Table 27.3: Changes in the chest

120 hr (5 days) 144 hr (6 days) 240 hr (10 days)

Internal Autopsy Findings Signs of live birth observed in the viscera such as: lungs, heart and gastrointestinal tract are as follows. Changes in the Lungs Changes are mainly because of respiration and are depicted in Table 27.5.

Figs 27.2A and B: (A) Concept of live birth: Full term is on the process of birth—head and face out of birth canal—is considered as a live born, (B) Just born baby

In criminal cases: Signs of live birth have to be demonstrated by autopsy examination of the newborn as usually law presumes that “Found dead is born dead”. External Autopsy Findings • General findings • Ear changes • Changes in the chest • Changes in the umbilical cord (Figs 27.3A to F). General findings: Absence of vernix caseosa and presence of clothing are suggestive of live birth. Ear changes: Absence of embryonic connective tissue or presence of air in the middle ear is suggestive of live birth. Changes in the chest: Table 27.3 summarises the changes in the chest of the child, which help to decide whether respired or not and there by live or dead born. Changes in the umbilical cord: Presence of ligature/marks of crushing by the artery forceps is suggestive of live birth. Table 27.4 summarises other changes in the stump attached to the child, which are not only suggestive of live birth, but also help to assess time since birth.17-19

Confirmatory Tests for Respiration in Lungs • Plaquet's test • Hydrostatic test (floatation test) • Histological examination of lung (Figs 27.4A and B). Plaquet's Test In this test, weight of the lung and body weight are compared. Normally the ratio of lung: body weight is 1:35. In unrespired lung this ratio cannot be maintained. Hydrostatic Test (Floatation Test) Bernard Knight in his classic Forensic Pathology, 2nd edition concludes 'Hydrostatic test is lightly studied black magic and is a complete waste of time' However, I differs with him pronounce that a salmon-pink spongy lungs that floats in water, is diagnostic of an infant who has breathed provided there is absence history of resuscitation and no putrefaction commenced, are most in keeping with lungs from." Here he shows aerated lungs floating in water in a case of alleged stillbirth without resuscitation. Byard refrains from giving his conclusions in this case, but he seems to have opined in favour of a live birth. Principle: Air that has entered into lung tissue during respiration makes it lighter and floats in water. It is also a fact that specific gravity of the lung before respiration is 1040-1050, which becomes 0.940 to 0.950 which is less than that of water, after respiration, and makes the respired lung float.

Procedure • Dissect out the fetal lungs • Put both the lungs into a trough of water and observe. 385

Part IV: Clinical Forensic Medicine Figs 27.3A to F: Umbilical chord in different phases of healing: (A) Just born newborn baby with umbilical cord attached just after a caesarean section, (B) Umbilical cord 3 minutes old age child with clamp applied, (C) Umbilical cord stump healing, (D) Umbilical cord stump of 7 days old baby, (E) Umbilical cord before falling, (F) Umbilical cord stump healed and detached from umbilicus

Table 27.5: Lung changes due to respiration Features

Respired

Unrespired

Pleura Diaphragm Margins/edges Surfaces Consistency Weight

Mottled pink High/voluminous Occupies fully the thoracic cavity, overlaps heart Taut and stretched At 6th rib level Round Uneven Spongy (crepitous) 1000 gm

Bluish red or uniformly reddish brown Low/small Not full. Lies at the back of the cavity behind heart Loose and wrinkled At 3rd rib level Sharp-liver like Smooth Solid-liver like About 500 gm

II. Cut section: Blood oozing

+ve

–ve

I. Gross findings: Colour Volume Position in thoracic cavity

Inference • If they sink—unrespired lung • If they float—remove them form water, cut into small pieces and then squeeze or press firmly between sponges, again put into the water column • If they sink—unrespired lung • If they float—respired lung. Explanation The floatation observed in the test above for the second time is mainly because of the "residual air" that remains in the lungs, which cannot be squeesed out by pressing, if the child has breathed after birth. 386

Fallacies A false-positive test of floatation of lung pieces may be observed in conditions such as: • Accumulation of putrefying gases • Air pushed into lung by artificial respirators, etc. A false-negative test of sinking of lung pieces can be observed in conditions such as: • Atelectasis • Pneumonic consolidation, etc. Histology of Lung Unrespired lung looks like section of parotid gland mainly because the alveoli with lining epithelium which is cubodial, while on

Heart Changes To understand this certain basics on foetal circulation may be essential and is discussed below (Figs 27.5 and 27.6) in brief: When the baby is still in the mother's womb it does not need to breathe for itself as the mother, via the umbilical cord, is supplying all the oxygen that the baby needs. The circulation before birth is different from that after birth. It is designed so that the oxygen filled blood from the umbilical cord goes to the most important part of the body, for example the brain. Thus, very little blood needs to go to the lungs.

Figs 27.4A and B: Microscopy of foetal lung: (A) Before respiration (unrespired lung). Note the glandular appearance as alveoli are yet to be filled with air and lining epithelium look like cuboidal epithelium, (B) After respiration (respired lung). Note: Flattened epithelium with expanded alveoli filled with air

Chapter 27: Infanticide, Foeticide and Child Abuse

entry of air into it, the cells get flattened with dilatation-pavement epithelium (see Figs 27.4A and B).

Fig. 27.5: Showing foetal heart and blood flow in it (Internet source: http://www.lhm.org.uk/Info/circulation-before-birth-35.aspx)

Fig. 27.6: Showing foetal heart and blood flow in it (Internet source: http://www.childrenscentralcal.org/HealthE/PublishingImages/em_0181.gif)

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There is a hole between the top collecting chambers (in the inter atrial septum of right and left atria) called the Foramen ovale: oxygen filled blood passes from the right collecting chamber to the left chamber through the hole and then on into the left pumping chamber (left ventricle) from where it is then pumped around the body. There is also a connection called the ductus arteriosus which joins the lung artery (Pulmonary artery) and the body artery (Aorta). Blood passes from the right pumping chamber up the lung artery, some blood then passes to the lungs but most flows through the ductus arteriosus to the body artery and then around the body, again avoiding the lungs. Thus, foramen ovale and ductus arteriosus act as bypass system of foetal circulation. When the baby is born and starts to breathe for itself, these bypass systems are no longer needed. Gradually over the first few days or weeks, after birth, the duct and the hole will close off and the baby's circulation will change to that in a normal heart. Thus, changes in the heart suggestive of live birth are: • Ductus arteriosus closure occurs on fourth day of birth • Foramen ovale closure occurs by second month of birth. GIT changes suggestive of live birth are: – Presence of food, saliva, etc. in the stomach – Presence of air in the stomach with no changes of decomposition – Presence of meconium in intestine (Meconium is inspissated bile and mucus, usually voided out by 24 to 28 hours of birth. So, if meconium is absent in the intestine, child is live birth). Fallacy-if it may be voided off, if the case is of delivery of breech presentation. Establishing Whether Dead Born The dead born fetus may undergo a typical change, which is called maceration. Macerated foetus: It is a state of aseptic autolysis occurring after the intrauterine death of a foetus (Fig. 27.7). On examination a macerated fetus shows following features: • Emits a rancid odour • Body is soft and pliable—it flattens when kept on a table • Skin—sodden and coppery red/purplish (never greenish as with putrefaction) with blisters, and peeling cuticle • Abdomen—distended • Umbilical cord—thick, red smooth, soft. • Joints—abnormally mobile or flexible • Body cavity—presents reddish serum within • Organs/viscera—soft and edematous, loose their morphology, but lungs and uterus remain unaffected for long period. • Skull bones—loss of alignment and over-riding of bones of cranial vault and overlapping (seen on radiograph, called as Spalding's sign) due to shrinkage of brain after death seen within few days of death of foetus16-17 (Fig. 27.8). Time required: Maceration begins or sets in 5 to 7 days prior to expulsion, thus, it needs about 5 to 7 days time to form.17

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Grades of Maceration (Table 27.6) There are five-grade scales based primarily on the external characteristics of the dead born. That scale of severity of maceration is as follows:16 1. None 2. Slight—skin slippage, rare bullae, little (e.g. scrotum only or single spots of skin loss elsewhere) or no denudation.

Fig. 27.7: Dead born macerated foetus. Note the soft pliable body, coppery red skin, thick umbilical cord, distended abdomen, etc

Table 27.6: Showing six of the measures applicable scale used in grading maceration16 Features

Interval between death and delivery

• Skin desquamation of > or =1 cm • Skin desquamation involving the face, back and/or abdomen • Skin desquamation involving at least 5 per cent of body surface • Change of skin coloration to tan or brown • Generalised skin desquamation • Mummification

> or = 6 hours > or =12 hours > or = 18 hours > or = 24 hours > or = 24 hours > or = 14 days

3. Mild—focal denudation of multiple regions without other changes 4. Moderate—generalised skin maceration/ denudation but without significant compressive changes 5. Advanced—compression and/or mummification and/or internal liquefaction. Based on these findings we can better estimate the relationship between maceration scale and time interval between death and delivery (Table 27.7).16 Time of Survival If Live Born A rough estimation on how long a child survived after birth can be done by following data. 1. Caput succedaneum changes: It is a haematoma formed within the skin of presenting part of baby during delivery. It begins to disappear by 24 hours of birth and completely not seen by 7 days of birth. If the infant examined shows the presence of Caput, then the period of survival after birth can be given 7 days (Figs 27.9A and B). 2. Umbilical cord changes (refer above)

3. Gastrointestinal changes (refer above) 4. Cardiovascular changes (refer above) 5. Changes in blood – Normoblasts will be present till 24 hours after birth. – Fetal haemoglobin will be detected in first six months after birth. Cause of Death Death of a newborn could be due to several reasons. Practice of perinatal autopsy in developed countries has revealed wide variety of causes and commonly they are shown in Flow chart 27.1.

Chapter 27: Infanticide, Foeticide and Child Abuse

Fig. 27.8: Spalding’s sign16-17 X-ray (left) and ultrasound (right) of the foetal skull. Note overlapping of skull bones and ribs—IUD of foetus

Natural causes such as immaturity or prematurity, debility or diseases, congenital anomalies being discussed elsewhere, others in the flow chart are considered here for brief discussion: Acts of omission This includes, not doing certain things necessary for an infant, e.g. • Avoid ligating umbilical cord before cutting • Avoid feeding the infant, etc. Flow chart 27.1: Causes of death in a newborn

Table 27.7: Time interval between death and delivery by maceration scale Maceration 1. 2. 3. 4. 5.

None Slight Mild Moderate Advanced

Interpretations of time interval between death and delivery Intrapartum death Less than 12 hours About 12-24 hours 1-2 days More than 2 days

Figs 27.9A and B: Caput succedaneum due to vacuum suction applied on presenting part—head

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Section 317 of IPC: Provides punishment of imprisonment of either description for a term which may extend to seven years or with fine or both for "Exposure and abandonment of child less than twelve years, by parent or person having care of it". Acts of commission: This includes doing certain deliberate acts resulting in the death of the infant, e.g. smothering the infant to death, strangulation and head injury. Prolonged labour: Here the fetus dies in uterus due to certain maternal causes such as contracted pelvis, cephalopelvic disproportion, etc. Precipitate labour: Here the fetus dies at delivery. The victim is usually a newborn infant, alleged to have died in the toilet, bathroom, etc. Here the mother is always a grand-multi and in such woman, three stages of labour are condensed into one single stage, and the fetus is passed out suddenly with the onset of labour pain taking short time, cause of death in the infant is usually head injury. Cord round the neck: During the delivery of a foetus the umbilical cord gets wound round the neck accidentally, resulting in death due to asphyxia, the cord acting like a ligature of hanging or strangulation.

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FOETICIDE Foeticide is a unique form of violence killing of a foetus, before being born. The term foeticide usually refer to total destruction of female foetus. Certainly, this is an atrocity against female and is actively being promoted by the sex determination clinics. This has assumed disproportionate growth in India recently by terminating birth of unwanted female child in northern India, while in the south, sex determination tests and abortions being considered as expensive, practice is to prefer to deliver the child and then kill it, if it is a girl.1-3 Economics of life has made the parents uncaring and heartless. Daughters are considered economic burdens to the family because of the high cost of weddings and dowries, while sons as providers of income, and are seen as type of insurance/ security by their parents. New prenatal sex-determination techniques, such as ultrasound, have led to an increase in the abortion of female foetuses rather than female infanticide. Female infanticide and abortion have increased in recent years also for other reasons such as women opt now for smaller families. In India the sex ratio is 93 women for every 100 men (i.e. F : M is 93:100), but in some regions this ratio is < 85 women per 100 men (i.e. F : M is